Empire Magic

Empire Magic Gift Certificate Order Form

Mail To:  99 Stratford Lane, Rochester, NY 14612-2981

Order 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.

 

I want to buy a 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:_______ Security Code: ________

 

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

 

Card Holder's Signature:______________________________________________________________________

 

 




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