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 ____________________________
____________________________
Email Address ____________________________    
Phone Number ____________________________

Purchaser's signature
____________________________

Donation Amount:
$ ____________(minimum $100.00)
     
       
   

PLEASE COMPLETE AND FAX TO: 202-222-0978.

If you are unable to fax the form, please provide the above information in an email to: sofab@acadianarestaurant.com with a note that authorizes Acadiana to charge your card.
Any questions, please call 202-222-0987.
All proceeds will go to the Southern Food and Beverage Museum. Tax ID number 33-1081281