Nextasea Inc.  
Our Time Saves You Time  
  HOME ::
   
 
Concierge Services: Grocery Order Form

The fee to receive this service is $25.00 with a $100.00 deposit for the groceries. The total amount you would need to initiate your order is $125.00. There is a $150.00 limit on your total grocery order, including the $25.00 fee. You will receive the receipt for the grocery order with any additional cost due upon delivery of your items. If the grocery order comes to less than $100.00, you would receive the change due to you upon delivery of your order.

To make a payment for this service with your credit card please see our online "Payment Form". If paying ahead by check, please make your payment out to "Nextasea, Inc." and mail to the following address: 15 Acorn Lane, Scarborough, ME, 04074 - 8642. Please mail your check one week prior to the requested shopping date, unless other specific arrangements have been made.

E-mail Linda

Telephone: 207.883.2547

YOUR CONTACT INFORMATION:

* Must complete all fields in this section in order to submit this form
First Name:* Last Name:* Telephone:* Email:*
Address for Delivery:*
Date of Delivery:*



DAIRY PRODUCTS:
Amount: Dairy Item #1: Size: Brand Name: Substitute: Specifics:
Amount: Dairy Item #2: Size: Brand Name: Substitute: Specifics:
Amount: Dairy Item #3: Size: Brand Name: Substitute: Specifics:
Amount: Dairy Item #4: Size: Brand Name: Substitute: Specifics:
Amount: Dairy Item #5: Size: Brand Name: Substitute: Specifics:



FRESH PRODUCE:
Amount: Fresh Produce Item #1: Size: Brand Name: Substitute: Specifics:
Amount: Fresh Produce Item #2: Size: Brand Name: Substitute: Specifics:
Amount: Fresh Produce Item #3: Size: Brand Name: Substitute: Specifics:
Amount: Fresh Produce Item #4: Size: Brand Name: Substitute: Specifics:
Amount: Fresh Produce Item #5: Size: Brand Name: Substitute: Specifics:



BAKERY GOODS:
Amount: Bakery Goods Item #1: Size: Brand Name: Substitute: Specifics:
Amount: Bakery Goods Item #2: Size: Brand Name: Substitute: Specifics:
Amount: Bakery Goods Item #3: Size: Brand Name: Substitute: Specifics:
Amount: Bakery Goods Item #4: Size: Brand Name: Substitute: Specifics:
Amount: Bakery Goods Item #5: Size: Brand Name: Substitute: Specifics:



MEATS:
Amount: Meats Item #1: Size: Brand Name: Substitute: Specifics:
Amount: Meats Item #2: Size: Brand Name: Substitute: Specifics:
Amount: Meats Item #3: Size: Brand Name: Substitute: Specifics:
Amount: Meats Item #4: Size: Brand Name: Substitute: Specifics:
Amount: Meats Item #5: Size: Brand Name: Substitute: Specifics:



FROZEN FOODS:
Amount: Frozen Foods Item #1: Size: Brand Name: Substitute: Specifics:
Amount: Frozen Foods Item #2: Size: Brand Name: Substitute: Specifics:
Amount: Frozen Foods Item #3: Size: Brand Name: Substitute: Specifics:
Amount: Frozen Foods Item #4: Size: Brand Name: Substitute: Specifics:
Amount: Frozen Foods Item #5: Size: Brand Name: Substitute: Specifics:



DRY/CANNED GOODS:
Amount: Dry/Canned Goods Item #1: Size: Brand Name: Substitute: Specifics:
Amount: Dry/Canned Goods Item #2: Size: Brand Name: Substitute: Specifics:
Amount: Dry/Canned Goods Item #3: Size: Brand Name: Substitute: Specifics:
Amount: Dry/Canned Goods Item #4: Size: Brand Name: Substitute: Specifics:
Amount: Dry/Canned Goods Item #5: Size: Brand Name: Substitute: Specifics:



BEVERAGES:
Amount: Beverage Item #1: Size: Brand Name: Substitute: Specifics:
Amount: Beverage Item #2: Size: Brand Name: Substitute: Specifics:
Amount: Beverage Item #3: Size: Brand Name: Substitute: Specifics:
Amount: Beverage Item #4: Size: Brand Name: Substitute: Specifics:
Amount: Beverage Item #5: Size: Brand Name: Substitute: Specifics:



MISCELLANEOUS:
Amount: Miscellaneous Item #1: Size: Brand Name: Substitute: Specifics:
Amount: Miscellaneous Item #2: Size: Brand Name: Substitute: Specifics:
Amount: Miscellaneous Item #3: Size: Brand Name: Substitute: Specifics:
Amount: Miscellaneous Item #4: Size: Brand Name: Substitute: Specifics:
Amount: Miscellaneous Item #5: Size: Brand Name: Substitute: Specifics:






 

 

© 2010 Nextasea Inc