| Who is purchasing the certificate? | ____________________________ | ||
| Credit card number | ____________________________ | Exp. _______________ | |
| Please provide copy of front and back of card with order; Acadiana will be unable to process order without copy. | |||
| Full name as it appears on card | ____________________________ | ||
| Address | ____________________________ | ||
| ____________________________ | |||
| Phone Number | ____________________________ | ||
Purchaser's signature |
____________________________ |
||
Denomination of certificate: |
$ ____________(minimum $25) |
||
| Subtotal | $ ________ | ||
| Overnight service fee? | $ 25.00 | ||
| TOTAL CHARGED TO CARD | $ ________ | ||
| Should Acadiana mail the certificate to the purchaser? | Yes _________No___________ | ||
| Where should Acadiana mail the certificate? | Name_____________________ | ||
| Address___________________ | |||
| _________________________ | |||
| PLEASE COMPLETE AND FAX TO: 202-408-0889 | |||
| Thank you for your order, please allow one week for standard mail delivery. | |||