1. Customer Information:
Title	Mr. Mrs. Ms. Miss
Full Name (required)
Job Title
Street Address Line 1 (required)
Street Address Line 2
Street Address Line 3
City (required)
State (required)	AK AL AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY OTHER
If other please specify
ZIP/Postal Code (required)
Day Phone (required)
Evening Phone
Fax
Email (required)
Contact me by	Email Telephone Fax
2. Customer Profile: Who are your recipients? Customer appreciation? Employee Appreciation? Thanks for the referral? Personal (consumer) gift?
Enter info about Profile in this box.
3. Occasion: Is this gift for a special occasion, i.e. Christmas, New Years, Easter, 4th of July, Thanksgiving? Personal gift occasions such as birthday, anniversary, get well, sympathy, new baby? If corporate, are you interested in a year-round corporate gifting program?
Enter info about Occasion in this box.
4. Budget: What is your desired budget range per gift? Is there more than one budget range?
Enter info about Budget in this box.
5. Basket Type: Are you interested in maintaining a corporate feel, or do you wishto be a bit more personable with your gifting needs?
Enter info about Basket type in this box.
6. Item Preference:
Please check items that you would like to include in your custom gift basket.	Gourmet Only Stationery items / Picture frames Mugs Company promo items (provided by customer) Golf items Calendars Relaxation / Aromatherapy Other (specify below)
Enter any additional info about Item Preference in this box.
7. Color / Theme Preference: Do you have a certain color preference for the theme of your basket? If corporate, are you interested in basket design using your company colors and imprinted ribbon with company name?
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8. Additional Requests: Do you have any addition requests?
Enter info about Additional Requests in this box.