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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.


Wholesale Order Form