Personalized by Design    (800) 945-5522                Birth Announcement Candy Bar ORDER FORM
DURING THE SUMMER MONTHS PLEASE INFORM IF WE SHOULD PACK WITH A COOLER   YES[  ]   No [  ] (Please check one)
Unmelted chocolate not guaranteed unless shipped in cooler to warm climates with no more than 1-4 day transit time.

 
 BABY INFORMATION         BOY [  ]               GIRL [  ]                MULTIPLES [  ] (Use separate form for each baby)   
   
Baby's Name: FIRST                                   MIDDLE   LAST      
Date of Birth:     Time: ______:______  [  ] a.m.     [  ] p.m.   
Weight: ______lbs. ______oz. Length: ______inches   
Birthplace:
  CITY                                                         STATE                                         ZIP  
           Mfd. by (Parents):  ______________________ and ______________________  _________________________
   MOTHER                                                                           FATHER                                                                   LAST (Optional)  
Siblings:
(Note Brother or Sister next to Unisex names:  i.e.:  Jordan, Jamie etc.)
Baby's Hometown:  CITY                                                         STATE                                         ZIP  
Mother's Maiden Name:      
                  
 
 Quantity:__________   DESIGN:__________   Graphic Choice:__________ (NB1&3 Only)
 With Chocolate [ ]     Wrappers only [ ]       [ ] (Hershey Bars Add 20 cents)         (Bear will be used if not indicated)   
                                                                                                                                   
 Transit time depends on time and day of receipt of order.  Shipping Charges are based on Quantity and Zone. 
 Ship Via    Ground (3-7 day) [  ]    Second Day (3-4 day) [  ]   Express (1-3 day) [  ]    
Transit time based on your zone location from New Jersey  .
                 
Is this a gift?   Yes [ ]  No [ ]      GIFT WRAP [  ] (includes small enclosure card) $6.00   LARGE GIFT CARD  [  ] $2.25  
Note for Enclosure card/Gift Card: ____________________________________________________________  
                 
 Payment: We accept:   VISA,  MASTER CARD, DISCOVER, CHECK CARDS, AMEX    
    Card Number: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|      Exp. Date: ___/___     
    Name as it appears on card:____________________________________________  
    Card Holder Phone:  (        )             -  
    Authorized Signature: X___________________________________________  
                                 **IMPORTANT:  Please provide Credit Card billing address in BILL TO: if different than Ship To:**  
                       Bill To:  NAME     Ship To:  NAME      
                                                 ADDRESS                                             APT# ADDRESS                                             APT#  
                                                   CITY/STATE/ZIP     CITY/STATE/ZIP      
                 
Checks and Money Orders also gladly accepted.      Allow 2 weeks clear time for checks 
Please call for shipping price if paying via Money order or Check
Mail completed form to:                       Personalized by Design
1141 Greenwood Lake Turnpike
Ringwood, New Jersey 07456
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