Order Form

Fill out this form and submit form via e-mail or print web page and fax/mail.

Mail to:

Scooter Bay-Dining DelicaSeas
799 Roosevelt Road
Building 2, Suite 109
Glen Ellyn, IL 60137

Fax to:

Corporate Fax: 630.545.9770

Purchaser Information
Name:
Company:
Address:
City:
State:
Zip Code:
Phone:
E-mail:
Please select your Dining DelicaSeas Package:

How Many?
Please type in order number for any additional Scooter Bay products:
	1 2 3
How would you like to be billed:	Check VISA Mastercard AMEX
Be aware that when submiting information over the internet, this is not a secure site. We recommend printing out this form and faxing it to us when using a credit card.
Name of Card Holder
Card Number
Exp. Date
Gift Recipient
Recipient's Name:
Company:
Address:
Is the address a Business or Residence?
City:
State:
Zip Code:
Phone:
Gift Card Message:
Gift Card Signed From:

Packages including wine can only be shipped to: IL, WV, MN, NE, ID, CA, NM, OR. "Additional Items" can be added to any of the packages, but are not shipped separately. All prices subject to change. Freight not included; average cost is $10-20 for most residential shipments.