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:______________________________________________________________________