Gift Certificate Order Form


 

Gift Certificate Order Form - Empire Magic

99 Stratford Lane, Rochester, NY 14612-2981

Order Hotline and Inquiries ~ (585) 227-9760

FAX Order Line ~ (585) 368-9569

 

Use your browser's "Print" feature to print a copy of this form.  Complete then mail or fax for prompt delivery.

 

Please provide an Empire Magic Gift Certificate in the amount of . . .
[__] $25 . . . . [__] $50 . . . . [__] $75 . . . . . . . . . [__] $________

 

Print clearly so your Gift Certificate is prepared without error.

 

This Gift is For:  Prepare the Gift Certificate using the receiver's ... [  ] First name only     [  ] Full name

 

Name:_______________________________________________________________________________________________

      

Address:_____________________________________________________________________________________________

 

City:___________________________________________         State:___________        Zip/Postal Code:_________________

 

 

 

This Gift is From:   Prepare the Gift Certificate using the giver's ... [  ] First name(s) only     [  ] Full name(s)

 

Name:________________________________________        E-mail Address:_______________________________________

 

Address:______________________________________________________________________________________________

 

City:___________________________________________         State:___________        Zip/Postal Code:__________________

 

Telephone: (________) ___________ - ________________        Date:________________________

 

 

 


 

Shall Empire Magic mail the completed Gift Certificate to ... [  ] Individual ordering      [  ] Individual receiving

 


 

Please complete this section if paying by credit card

 

[   ] Mastercard      [   ] Visa      [   ] Discover 

 

Card Number:____________________________________________________ Expiration Date:_____________________

 

Print card holder's name as it appears on the card:_________________________________________________________ 

 

Card Holder's Signature:______________________________________________________________________________

 

 




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