* = required information
1. Customer
Your First Name *
Your Last Name *
Email Address *
Daytime Phone *
Evening Phone
If you have ordered with Food Chain before and your delivery and mailing information is the same, you may skip to Delivery Details
2. Delivery Address
Company/ Organization: (if applicable)
Street Address
Cross Streets ("between X and Y" or "corner of X")
Zip
3. Mailing Address (if different from Delivery Address)
Company/ Organization: (if applicable)
Street Address
City
State
Zip
4. Delivery Details
* # of meals to deliver *
* Date of Delivery * (dd/mm/yyyy, numbers only, e.g. 01/15/2000)
Delivery Instructions (e.g. where to leave meal and pick up payment, location of keys, etc.)
Alternate Delivery Instructions (In case we are unable to follow your instructions, please indicate another method of delivery, like a location close by where we can leave your meal.)
How did you hear about Food-Chain?	a friend/coworker saw us on delivery other (please specify)
If a Food Chain customer told you about us, please tell us who so we can thank them.
5. Payment Information
Method*	check at delivery BREAD at delivery. Visa/Mastercard
Card #
Expiry Date (mm/yy)
6. Service Agreement
"I understand that Food Chain is a small business and that every meal costs Food Chain money and effort to prepare and deliver. If there is a problem with my delivery instructions, for instance no one is there to receive the meal when I said there would be, Food Chain will make a reasonable attempt to leave the food elsewhere, but if delivery is not possible I am still responsible for promptly paying for the meal. I also understand that Food Chain will make all reasonable efforts to notify me if there is a problem delivering my order, and that if I am not satisfied with my meal, I may request a credit or refund." Type your full name to indicate you have read and agree to the Service Agreement:
* *