Wholesale Order Form

<p>Please note prices will be invoiced as per your price plan agreed with your Account Manager. If you do not have a price plan agreed, please fill in the Wholesale &amp; Distribution page and a member of our team will contact you shortly. Please complete the form as accurately as possible, enter the number of bottles required per brand in the boxes below the required flavour.</p>
<form method="post" enctype="text/plain" action="mailto:jay@concentrateswarehouse.co.uk">
<div><label for="name">Name:</label> <input type="text" id="name" name="user_name" required="required" size="" />
<div>
<div><label for="mail">E-mail:</label> <input type="text" id="mail" name="user_email" required="required" /></div>
<div><label for="business">Business Name:</label> <input type="text" id="business" name="Business_Name" required="required" /></div>
<div><label for="delivery">Delivery Address:</label> <input type="text" id="delivery" name="user_delivery" required="required" />
<div><label for="phone">Contact Number:</label> <input type="number" id="phone" name="user_phone" required="required" /></div>
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<h1>Pancake Prince - 80ml - 80/20 - Boxed</h1>
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<div><label for="bluberry ice cream">Blueberry Ice Cream:</label> <input type="number" id="bluberry ice cream" name="blueberry_ice_cream" /></div>
<div><label for="Butterscotch Clotted Cream">Butterscotch Clotted Cream:</label> <input type="number" id="butterscotch clotted cream" name="butterscotch_clotted_cream" /></div>
<div><label for="Maple &amp; Pecan">Maple &amp; Pecan:</label> <input type="number" id="maple &amp; pecan" name="maple_&amp;_pecan" /></div>
<div><label for="Peanut Butter &amp; Banana">Peanut Butter &amp; Banana:</label> <input type="number" id="peanut butter &amp; banana" name="peanut_butter_&amp;_banana" /></div>
<div><label for="Honey &amp; Lemon">Honey &amp; Lemon:</label> <input type="number" id="Honey &amp; Lemon" name="Honey_&amp;_lemon" /></div>
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<h1>Donut King - 80ml - 80/20 - Boxed</h1>
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<div><label for="raspberrycoconut">Raspberry &amp; Coconut:</label> <input type="number" id="raspberrycoconut" name="raspberrycoconut" /></div>
<div><label for="strawberriescream">Strawberries &amp; Cream:</label> <input type="number" id="strawberriescream" name="strawberriescream" /></div>
<div><label for="deepfried">Deep Fried Donuts:</label> <input type="number" id="deepfried" name="deepfried" /></div>
<div><label for="vanillacustard">Vanilla Custard:</label> <input type="number" id="vanillacustard" name="vanillacustard" /></div>
<div><label for="cinnamonapple">Cinnamon &amp; Apple:</label> <input type="number" id="cinnamonapple" name="cinnamonapple" /></div>
<div><label for="delightfullemon">Delightful Lemon:</label> <input type="number" id="delightfullemon" name="delightfullemon" /></div>
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<h1>Cookie Queen - 80ml - 80/20 - Boxed</h1>
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<div><label for="raspberrywhitechoc">Raspberry White Chocolate:</label> <input type="number" id="raspberrywhitechoc" name="raspberrywhitechoc" /></div>
<div><label for="Coconutcookie">Coconut Cookie:</label> <input type="number" id="coconutcookie" name="Coconutcookie" /></div>
<div><label for="Salted Caramel">Salted Caramel:</label> <input type="number" id="SaltedCaramel" name="SaltedCaramel" /></div>
<div><label for="milkchocolate">Milk Chocolate:</label> <input type="number" id="milkcocolate" name="milkchocolate" /></div>
<div><label for="orangecookie">Orange Cookie:</label> <input type="number" id="orangecookie" name="orangecookie" /></div>
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<h1>Very Jelly - 50ml - 70/30 - Boxed</h1>
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<div><label for="vanilla">Vanilla:</label> <input type="number" id="vanilla" name="vanilla" /></div>
<div><label for="toastedmarshmellow">Toasted Marshmellow:</label> <input type="number" id="toastedmarshmellow" name="toastedmarshmellow" /></div>
<div><label for="strawberryjam">Strawberry Jam:</label> <input type="number" id="strawberryjam" name="strawberryjam" /></div>
<div><label for="raspberry">Raspberry:</label> <input type="number" id="raspberry" name="raspberry" /></div>
<div><label for="popcorn">Popcorn:</label> <input type="number" id="popcorn" name="popcorn" /></div>
<div><label for="peach">Peach:</label> <input type="number" id="peach" name="peach" /></div>
<div><label for="orange">Orange:</label> <input type="number" id="orange" name="orange" /></div>
<div><label for="menthole">Menthol:</label> <input type="number" id="menthol" name="menthol" /></div>
<div><label for="liquorice">Liquorice:</label> <input type="number" id="liquorice" name="liquorice" /></div>
<div><label for="lime">Lime:</label> <input type="number" id="lime" name="lime" />
<div><label for="lemon">Lemon:</label> <input type="number" id="lemon" name="lemon" /></div>
<div><label for="kiwi">Kiwi:</label> <input type="number" id="kiwi" name="kiwi" />
<div><label for="pear">Pear:</label> <input type="number" id="pear" name="pear" />
<div><label for="greenapple">Green Apple:</label> <input type="number" id="greenapple" name="greenapple" /></div>
<div><label for="cottoncandy">Cotton Candy:</label> <input type="number" id="cottoncandy" name="cottoncandy" /></div>
<div><label for="coconut">Coconut:</label> <input type="number" id="coconut" name="coconut" /></div>
<div><label for="cinnamon">Cinnamon:</label> <input type="number" id="cinnamon" name="cinnamon" /></div>
<div><label for="chocolatepudding">Chocolate Pudding:</label> <input type="number" id="Chocolatepudding" name="chocolatepudding" /></div>
<div><label for="cherry">Cherry:</label> <input type="number" id="cherry" name="cherry" /></div>
<div><label for="cappuccino">Cappuccino:</label> <input type="number" id="cappuccino" name="cappuccino" /></div>
<div><label for="Bubblegum">Bubblegum:</label> <input type="number" id="Bubblegum" name="Bubblegum" /></div>
<div><label for="blueberry">Blueberry:</label> <input type="number" id="Blueberry" name="Blueberry" /></div>
<div><label for="banana">Banana:</label> <input type="number" id="banana" name="banana" /></div>
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<h1>Pick 'n" Mix - 100ml - 70/30</h1>
<h1></h1>
<div><label for="fruit salad">Fruit Salad:</label> <input type="number" id="fruitsalad" name="fruitsalad" /></div>
<div><label for="Fizzybubblegum">Fizzy Bubblegum:</label> <input type="number" id="fizzybubblegum" name="fizzybubblegum" /></div>
<div><label for="peardrops">Pear Drops:</label> <input type="number" id="peardrops" name="peardrops" /></div>
<div><label for="Spearmintchews">Spearmint Chews:</label> <input type="number" id="spearmintchews" name="spearmintchews" /></div>
<div><label for="sherbetlemon">Sherbet Lemons:</label> <input type="number" id="sherbetlemon" name="sherbetlemon" /></div>
<div><label for="watermelonslices">Watermelon Slices:</label> <input type="number" id="watermelonslices" name="watermelonslices" /></div>
<div><label for="strawberrymilkshake">Strawberry Milkshake:</label> <input type="number" id="strawberrymilkshake" name="strawberrymilkshake" /></div>
<div><label for="rhubarbcustard">Rhubarb &amp; Custard:</label> <input type="number" id="rhubarbcustard" name="rhubarbcustard" /></div>
<div><label for="blueraspberry">Blue Raspberry:</label> <input type="number" id="blueraspberry" name="blueraspberry" /></div>
<div><label for="applecustardballs">Apple Custard Balls:</label> <input type="number" id="applecustardballs" name="applecustardballs" /></div>
<div><label for="buttermentos">Butter Mentos:</label> <input type="number" id="buttermentos" name="buttermentos" /></div>
<div><label for="fizzycolabelts">Fizzy Cola Belts:</label> <input type="number" id="fizzycolabelts" name="fizzycolabelts" /></div>
<div><label for="fizzycherrycolabottles">Fizzy Cherry Cola Bottles:</label> <input type="number" id="fizzycherrycolabottles" name="fizzycherrycolabottles" /></div>
<div><label for="Jellybabies">Jelly Babies:</label> <input type="number" id="jellybabies" name="jellybabies" /></div>
<div><label for="blackjacks">Blackjacks:</label> <input type="number" id="blackjacks" name="blackjacks" /></div>
<div><label for="SourCherry">Sour Cherry:</label> <input type="number" id="sourcherry" name="sourcherry" /></div>
<div><label for="strawberrybelts">Strawberry Belts:</label> <input type="number" id="strawberrybelts" name="strawberrybelts" /></div>
<div><label for="vanillafudge">Vanilla Fudge:</label> <input type="number" id="vanillafudge" name="vanillafudge" /></div>
<div><label for="sourapple">Sour Apple:</label> <input type="number" id="sourapple" name="sourapple" /></div>
<div><label for="foambanana">Foam Bananas:</label> <input type="number" id="foambanana" name="foambanana" /></div>
<div><label for="colabottles">Cola Bottles:</label> <input type="number" id="colabottles" name="colabottles" /></div>
<div><label for="cherrylips">Cherry Lips:</label> <input type="number" id="cherrylips" name="cherrylips" /></div>
<div><label for="blackliquorice">Black Liquorice:</label> <input type="number" id="Black Liquorice" name="blackliquorice" /></div>
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<h1>Ice Cream Van - 100ml - 70/30</h1>
<div><label for="strawberrysplit">Strawberry Split:</label> <input type="number" id="strawberrysplit" name="strawberrysplit" /></div>
<div><label for="lemonadelolly">Lemonade Lolly:</label> <input type="number" id="lemonadelolly" name="lemonadelolly" /></div>
<div><label for="raspberryvanillasherbet">Raspberry Vanilla Sherbet:</label> <input type="number" id="raspberryvanillasherbet" name="raspberryvanillasherbet" /></div>
<div><label for="bananasplit">Banana Split:</label> <input type="number" id="bananasplit" name="bananasplit" /></div>
<div><label for="tropicaltwister">Tropical Twister:</label> <input type="number" id="tropicaltwister" name="tropicaltwister" /></div>
<div><label for="raspberryripple">Raspberry Ripple:</label> <input type="number" id="raspberryripple" name="raspberryripple" /></div>
<div><label for="originaltwister">Original Twister:</label> <input type="number" id="originaltwister" name="originaltwister" /></div>
<div><label for="strawberrytwister">Strawberry Twister:</label> <input type="number" id="strawberrytwister" name="strawberrytwister" /></div>
<h1></h1>
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<h1>Lush Juice - 100ml - 70/30</h1>
<div><label for="blueberryjamwaffles">Blueberry Jam Waffles:</label> <input type="number" id="blueberryjamwaffles" name="blueberryjamwaffles" /></div>
<div><label for="bananaaniseed">Banana Aniseed:</label> <input type="number" id="bananaaniseed" name="bananaaniseed" /></div>
<div><label for="ricepudding">Rice Pudding:</label> <input type="number" id="ricepudding" name="ricepudding" /></div>
<div><label for="mintcaramelcoffee">Mint Caramel Coffee:</label> <input type="number" id="mintcaramelcoffee" name="mintcaramelcoffee" /></div>
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<h1>Moo Shakes - 100ml - 70/30</h1>
<div><label for="vanillamoo">Vanilla Moo:</label> <input type="number" id="vanillamoo" name="vanillamoo" /></div>
<div><label for="strawberrymoo">Strawberry Moo:</label> <input type="number" id="strawberrymoo" name="strawberrymoo" /></div>
<div><label for="chocolatemoo">Chocolate Moo:</label> <input type="number" id="chocolatemoo" name="chocolatemoo" /></div>
<div><label for="bananamoo">Banana Moo:</label> <input type="number" id="bananamoo" name="bananamoo" /></div>
<h1></h1>
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<h1>Fruitilicious - 100ml - 70/30</h1>
<div><label for="mixedberries">Mixed Berries:</label> <input type="number" id="mixedberries" name="mixedberries" /></div>
<div><label for="clearcherry">Clear Cherry:</label> <input type="number" id="clearcherry" name="clearcherry" /></div>
<div><label for="lemonlime">Lemon &amp; Lime:</label> <input type="number" id="lemonlime" name="lemonlime" /></div>
<div><label for="clearstrawberry">Clear Strawberry:</label> <input type="number" id="clearstrawberry" name="clearstrawberry" /></div>
<div><label for="appleraspberry">Apple &amp; Raspberry:</label> <input type="number" id="appleraspberry" name="appleraspberry" /></div>
<div><label for="strawberrykiwi">Strawberry Kiwi:</label> <input type="number" id="stawberrykiwi" name="strawberrykiwi" /></div>
<div><label for="summerfruits">Summer Fruits:</label> <input type="number" id="Summer Fruits" name="Summer Fruits" /></div>
<h1></h1>
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<h1>Smoothers - 100ml - 70/30</h1>
<div><label for="raspberrypeach">Raspberry Peach:</label> <input type="number" id="raspberrypeach" name="raspberrypeach" /></div>
<div><label for="lemonhoney">Lemon &amp; Honey:</label> <input type="number" id="lemonhoney" name="lemonhoney" /></div>
<div><label for="blackcurrant">Blackcurrant:</label> <input type="number" id="blackcurrant" name="blackcurrant" /></div>
<div><label for="cherrysmoother">Cherry:</label> <input type="number" id="cherrysmoother" name="cherrysmoother" /></div>
<div><label for="strawberrysmoother">Strawberry:</label> <input type="number" id="strawberrysmoother" name="strawberrysmoother" /></div>
<h1></h1>
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<h1>Biscuit Man - 100ml - 70/30</h1>
<div><label for="custardcreams">Custard Creams:</label> <input type="number" id="custardcreams" name="custardcreams" /></div>
<div><label for="goldencrunch">Golden Crunch:</label> <input type="number" id="goldencrunch" name="goldencrunch" /></div>
<div><label for="partyringers">Party Ringers:</label> <input type="number" id="partyringers" name="partyringers" /></div>
<div><label for="biscov">Biscov:</label> <input type="number" id="cottoncandy" name="Biscov" /></div>
<div><label for="pinkywafer">Pinky Wafer:</label> <input type="number" id="pinkywafer" name="pinkywafer" /></div>
<h1></h1>
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<h1>Frozen Cola - 100ml - 70/30</h1>
<div><label for="cherrycola">Cherry Cola:</label> <input type="number" id="cherrycola" name="cherrycola" /></div>
<div><label for="vanillacola">Vanilla Cola:</label> <input type="number" id="vanillacola" name="vanillacola" /></div>
<div><label for="colazero">Cola Zero:</label> <input type="number" id="colazero" name="colazero" /></div>
<div><label for="blueberrycola">Blueberry Cola:</label> <input type="number" id="blueberrycola" name="blueberrycola" /></div>
<h1></h1>
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<h1>Fruity Tooty - 100ml - 70/30</h1>
<div><label for="blackcurranttf">Blackcurrant:</label> <input type="number" id="blackcurrant" name="balckcurrant" /></div>
<div><label for="limetf">Lime:</label> <input type="number" id="limetf" name="limetf" /></div>
<div><label for="lemontf">Lemon:</label> <input type="number" id="lemontf" name="lemontf" /></div>
<div><label for="orangetf">Orange:</label> <input type="number" id="orangetf" name="ornagetf" /></div>
<div><label for="strawberrytf">Strawberry:</label> <input type="number" id="strawberrytf" name="strawberrytfy" /></div>
<h1></h1>
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<h1>Mood Juice - 100ml - 70/30</h1>
<div><label for="pineapplebananacoconut">Pineapple, Banana &amp; Coconut:</label> <input type="number" id="pineapplebananacoconut" name="pineapplebananacoconut" /></div>
<div><label for="strawberryblackcurrantraspberry">Strawberry, Blackcurrant &amp; Raspberry:</label> <input type="number" id="strawberryblackcurrantraspberry" name="strawberryblackcurrantraspberry" /></div>
<div><label for="sourcherrymj">Sour Cherry:</label> <input type="number" id="sourcharrymj" name="sourcherrymj" /></div>
<div><label for="bananaaniseedmj">Banana Aniseed:</label> <input type="number" id="bananaaniseedmj" name="bananaaniseedmj" /></div>
<div><label for="spearmint">Spearmint:</label> <input type="number" id="spearmint" name="spearmint" /></div>
<div><label for="iceberg">Iceberg:</label> <input type="number" id="iceberg" name="iceberg" /></div>
<div><label for="deepfriedmj">Deep Fried Donut:</label> <input type="number" id="deepfriedmj" name="deepfriedmj" /></div>
<div><label for="raspberryripplemj">Raspberry Ripple:</label> <input type="number" id="raspberryripplemj" name="raspberryripplemj" /></div>
<div><label for="peachpassionfruit">Peach &amp; Passionfruit:</label> <input type="number" id="peachpassionfruit" name="peachpassionfruit" /></div>
<div><label for="blueberryjam">Blueberry Jam:</label> <input type="number" id="blueberryjam" name="blueberryjam" /></div>
<div><label for="LemonadeLollymj">Lemonade Lolly:</label> <input type="number" id="lemonadelollymj" name="lemonadelollymj" /></div>
<div><label for="grapeslush">Grape Slush:</label> <input type="number" id="grapeslush" name="grapeslush" /></div>
<h1></h1>
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<h1>Sub Zero - 100ml - 70/30</h1>
<div><label for="raspberryice">Raspberry Ice:</label> <input type="number" id="raspberryice" name="raspberryice" /></div>
<div><label for="Icebergsz">Iceberg (Heisenberg):</label> <input type="number" id="icebergsz" name="icebergsz" /></div>
<div><label for="blueberryice">Blueberry Ice:</label> <input type="number" id="blueberryice" name="blueberryice" /></div>
<div><label for="tropicaltwist">Tropical Twist Ice:</label> <input type="number" id="tropicaltwist" name="tropicaltwist" /></div>
<div><label for="appleice">Apple Ice:</label> <input type="number" id="Appleice" name="appleice" /></div>
<div><label for="strawberryice">Strawberry Ice:</label> <input type="number" id="strawberryice" name="strawberryice" /></div>
<div><label for="cherryice">Cherry Ice:</label> <input type="number" id="cherryice" name="cherryice" /></div>
<div><label for="purementhol">Prue Menthol Ice:</label> <input type="number" id="purementhol" name="purementhol" /></div>
<div><label for="RedAffair">Red Affiar Ice:</label> <input type="number" id="redaffair" name="redaffair" /></div>
<div><label for="lemonice">Lemon Ice:</label> <input type="number" id="lemonice" name="lemonice" /></div>
<div><label for="forrestfruitssz">Forrest Fruits Ice:</label> <input type="number" id="forrestfruitssz" name="forrestfruitssz" /></div>
<div><label for="blackcurrentice">Blackcurrant Ice:</label> <input type="number" id="blackcurrantice" name="blackcurrantice" /></div>
<div><label for="mangoice">Mango Ice:</label> <input type="number" id="mangoice" name="mangoice" /></div>
<div><label for="pineappleice">Pineapple Ice:</label> <input type="number" id="pineappleice" name="pineappleice" /></div>
<div><label for="bananaice">Banana Ice:</label> <input type="number" id="bananaice" name="bananaice" /></div>
<h1></h1>
<hr />
<h1>Vapers Delight - 100ml - 70/30</h1>
<div><label for="butterscotchvd">Butterscotch:</label> <input type="number" id="butterscotchVD" name="butterscotchvd" /></div>
<div><label for="strawberryvd">Smooth Strawberry:</label> <input type="number" id="strawberryvd" name="strawberryvd" /></div>
<div><label for="chocolatevd">Creamy Chocolate:</label> <input type="number" id="chocolatevd" name="chocolatevd" /></div>
<div><label for="bananavd">Fluffy Banana:</label> <input type="number" id="bananavd" name="bananavd" /></div>
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<div><label for="notes">Notes:</label> <input type="text" id="notes" name="note"  size="" /> <input type="submit" value="Send" size="" /></div>
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</form>