To order today simply print this page, complete this form and fax it to (202) 686-1533.
Please allow one week for standard mail delivery.
Who is purchasing the certificate? ______________________________
Credit Card Number: ______________________________ Exp._______
Full Name as it appears on card: ______________________________
Billing Address for Cardholder: _______________________________
_______________________________
Phone Number: ________________________________
Cardholder’s Signature ________________________________
Denomination of Certificate: $_________________
($10, $25, $50)
Quantity: __________________
Subtotal $_________________
Total Charged to Card $_________________
Mail the certificate to the purchaser? Yes________
Where to mail the certificate? Name_________________________
Address:__________________________________
__________________________________________