R E S T A U R A N T

Gift Certificate Order Form

To order today simply print this page, complete this form and either fax it to (202) 408-0889,
mail Gift Certificate Order Form to:
Acadiana Resturant, 901 New York Ave., NW, Washington, DC 20001 (no cash, please.)

Please use one form per certificate.

Who is purchasing the certificate? ____________________________
Credit card number ____________________________ Exp. _______________
Full name as it appears on card ____________________________ CID Code: _________
Please provide copy of front and back of card with order; Acadiana will be unable to process order without copy.
Billing Address ____________________________
____________________________

Billing Phone Number

Billing Email

____________________________

____________________________

Purchaser's signature
____________________________

Denomination of certificate:
$ ____________(minimum $25)
  Subtotal $ ________
Overnight service fee? $      30.00
TOTAL CHARGED TO CARD $ ________
   
       
Should Acadiana mail the certificate to the purchaser? Yes _________No___________    
Where should Acadiana mail the certificate? Name_____________________    
  Address___________________    
_________________________
Thank you for your order, please allow one week for standard mail delivery.