Order Form

Dearest ChocoLover,

If you’re having any issues placing an order online for any reason, we would be happy to process it for you manually!

Please submit the form below and wait to hear from us - we will email or call (select preference below) to verify before charging!

Thank you SO MUCH for your patience with online ordering!
With Love,
Chocolate Girl aka Vanessa & Mamma Wonka aka Aida

ps - please note this might delay your order by 24-48 hours

Name

First Name

Last Name

Email

Phone

(###)

###

####

Items ordered & how many of each (choose ANY of our products from www.gnosischocolate.com/shop-all/everything

SHIPPING

Ship to Name

First Name

Last Name

Ship to Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

BILLING

Name on Card

First Name

Last Name

Credit Card

Mastercard Visa Amex Discover

Expiration Date

leave the day 01

MM

DD

YYYY

CVV

3 digit verification (4 digits for Amex)

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SPECIAL INSTRUCTIONS

Requests, comments, suggestions, short gift note, delivery date, etc:

Would you prefer we reach you via phone or email? What's the best time of day for you?

Anything else?

Order Form

Thank You, ChocoLover!