Gift Certificate Order Form
Please print and complete this form and fax it to us at 213-622-8780. Your order will be confirmed via telephone and available for pick-up or mailed promptly (USPS - First Class).
I would like ______ (quantity) $25 gift certificates (Total $______)
I would like ______ (quantity) $50 gift certificates (Total $______)
I will pick-up my order on ____/____/____ or
Please mail my order to (one mailing address per form)
| Name: |
________________________________________________
|
| Address: |
________________________________________________
|
| City, State, ZIP: |
________________________________________________
|
I hereby authorize Engine Co. No. 28 Restaurant to charge my credit card $________
on the following date ____/____/____. |
| Credit Card Type: |
___ MC / ___ VISA / ___ AX / ___ DINERS
|
| Name on Card: |
________________________________________________
|
| Account Number: |
________________________________________________
|
| Expiration Date: |
________________________________________________
|
| Billing Address: |
________________________________________________
|
| |
________________________________________________
|
| |
________________________________________________
|
| Cardholder's Signature: |
________________________________________________
|
| Phone Number: |
________________________________________________ |
