| Dutch Haven Restaurant 201 East Bald Eagle Street Lock Haven PA 17745 Phone: (570) 748-7444 Fax: (570) 748-4779 Or Email: dutchhavenrestaurant@yahoo.com COPY AND PASTE ENTIRE FORM INTO AN EMAIL, OR PLEASE PRINT OUT, FILL IN AND MAIL TO THE ABOVE ADDRESS OR FAX TO: (570) 748-4779 ------------------------------------------------------------------------------------------------------------------------- Please make out Gift Certificate in the Name of: __________________________________________ . In the amount of U.S. $ ______________________ . FROM: Last Name: _________________________________ First Name (S): _________________________. Mailing Address: ____________________________________________________________________ City: __________________________________ State: _________ Zip Code: _______________. Phone: _____________________________________ Email: _________________________________. TO: Last Name: _________________________________ First Name (S): _________________________. Mailing Address: ____________________________________________________________________ City: _________________________________ State: _________ Zip Code: _______________. Phone: _____________________________________ Email: _________________________________. --------------------------------------------------------------------------------------------------------------------------- IMPORTANT: Gift Certificates have to be ordered at least 10 days before the date you would like to hand it out or have it received. In lieu of my credit card imprint, I, __________________________________________________, (Name of Cardholder as Shown on Credit Card) hereby authorize DUTCH HAVEN RESTAURANT, (Lock Haven, PA) to charge to my: VISA / MASTERCARD ___________________ ________ __________________________ Or DISCOVER (Circle One Please) Card Number Exp. Date Card Holder Signature The amount of U.S.$ ____________ Being payment for the gift certificate. The total amount being charged to my card is U.S.$ __________________. ------------------------------------------------------------------------------------------------------------------------------ TERMS & CONDITIONS: This form signifies acceptance of charges specified in writing by the cardholder that will be billed to the cardholder. Faxing, mailing or emailing signifies acceptance of charges. We accept credit card orders only. (VISA, MASTERCARD or DISCOVER) WE CANNOT ACCEPT PERSONAL CHECKS – CREDIT CARD ONLY. THANKS! |
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