Form ___ of ___
Order # _______
New Retailer: yes / no
171 Lily Street • San Francisco, California • 94102 hello@lilikoi-design.com • 213.798.4502 • www.lilikoi-design.com • @lilikoidesign
Company ____________________________
Billing Address _________________________
Order Date ____________________________
_____________________________________
Contact _____________________________
Shipping (if different) ______________________
Email ______________________________
_____________________________________
Phone ______________________________
Payment: Card* / Check / Card on File __ __ __ __
Best way to reach you: phone / email
Name on Card _________________________
Catalog Preference: print / online
# ________________________________
Requested Delivery Date ___________________
EXP _______ CCV______ Zip Code _________
SKU
NAME/DESCRIPTION
BOX
No.
SINGLE
*A 3% processing fee will apply for all credit card transactions. We will contact you via email or phone upon receiving your order and provide you with an expected ship date. Shipping times may vary depending on the season.
QTY
UNIT $
TOTAL $
1 2 3 4 5 6 7 8 9 10 11 12
NOTES
SHIPPING TOTAL
SIGNATURE ___________________________________
Thank you so much for your order!
Your signature authorizes that you have read and agree to our wholesale terms and for your credit card to be charged on your ship date.