FILL in COMPLETELY (Please Print)

2017 HOLIDAY PREORDER FORM

① PLACE YOUR ORDER ② FILL IN COMPLETELY (please print): ITEMS PRICE Contact: HOLIDAY PACKAGES Contact Phone: Sufganyiot Party Tray – LARGE (30 donuts) 55.00 Email: Available Dec. 11 - 18 Choose One: LINCOLN PARK RIVER NORTH OAK PARK Sufganiyot Party Tray – SMALL (15 donuts) 30.00 (2453 N. Clark St.) (68 W. Hubbard) (104 N. Maple Ave.) Available Dec. 11 - 18 Pick-Up Date & Time: Holiday Party Tray (24 donuts) 54.00 Available through Dec. 31 Delivery Date & Time (two hour window): Mini Donut Party Tray – LARGE (30 donuts) 55.00 (flat rate based on location) (Vanilla Iced, Chocolate Iced, Honey Glazed) Deliver To: Mini Donut Party Tray – SMALL (15 donuts) 30.00 (Vanilla Iced, Chocolate Iced, Honey Glazed) Delivery Address: DONUTS ALA CARTE Sufganyiot 2.24 ③ Peppermint Hot Chocolate 2.24 Message: : Eggnog 2.24 Red Velvet 2.24 Sugar Cookie 2.24 Wildflower Honey Glazed 2.55 Valrhona Chocolate Iced 2.95 ④ PLEASE COMPLETE YOUR PAYMENT INFORMATION: Tahitian Vanilla Iced 2.95 I, , (credit card holder’s name) authorize Firecakes to charge Buttermilk Old Fashioned 2.35 my credit card according to the order form plus Chicago’s sales tax and/or any additional fees, if Pistachio Old Fashioned 2.95 applicable. I guarantee full payment of the account as described. Triple Chocolate Cake 2.75 Type of credit card: ☐ Amex ☐ Visa ☐ MasterCard ☐ Discover Seasonal Fritter (Apple) 3.75 Card Number: Coconut Cream 2.85 Expiration Date: CVV2 Number: Classic Jelly (Raspberry Blood Orange) 2.85 (3-digit number located on the back of your card. For AMEX only, it is the 4-digit number on the front of your card) Sprinkle Donut 2.65 Signature of authorized user or authorized agent of the authorized user Gluten Free/Vegan 3.75 Full imprinted name as it appears on the card SUBTOTAL SALES TAX (Chicago – 11.5%, Oak Park – 10%) Billing address of the cardholder:

TOTAL ⑤ EMAIL YOUR COMPLETED FORM BY 3 P.M. THE DAY BEFORE TO [email protected]. FOR ANY QUESTIONS, PLEASE CALL 773-857-1729 Office Use Only: confirmation number______

68 W. Hubbard Street ● Chicago, IL 60654 ● Phone 312-329-6500 2453 N. Clark Street ● Chicago, IL 60614 ● Phone 773-666-5277 104 N. Maple Avenue ● Oak Park, IL 60301 ● Phone708-948-7052 www.firecakesdonuts.com ● [email protected] ⑥ PLEASE BE ASSURED YOU WILL RECEIVE AN EMAIL CONFIRMATION SHORTLY.

68 W. Hubbard Street ● Chicago, IL 60654 ● Phone 312-329-6500 2453 N. Clark Street ● Chicago, IL 60614 ● Phone 773-666-5277 104 N. Maple Avenue ● Oak Park, IL 60301 ● Phone708-948-7052 www.firecakesdonuts.com ● [email protected]