Contact Information
Title
Title
Mr.
Mrs.
Ms.
Dr.
Rabbi
Mr. & Mrs.
Dr. & Mrs.
*
First Name
*
Last Name
*
Address
*
City
*
Province
*
P.S.
*
Email
*
Order Info
All orders are to be picked up at 544 / 1034 S. Clair Ave West.
Type
# of Boxes
Amount
Total
Kfar Chabad
25.00
Ukraine
25.00
Splet
45.00
Gluten Free
45.00
Total
Payment Information
Order Amount
*
Select Amount
$18
$54
$108
$180
$360
$540
$770
Other
Total Amount
*
Card Type
Card Type
Visa
MC
Amex
*
Card Number
*
Card Expiration
Month
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
*
Year
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
*
Security Code
*
Same as above
Name on Card
*
Billing Address
*
P.S.
*
Submit