Please provide your daytime and evening phone numbers:
___________________________
___________________________
Name and address of where you
want the gift certificate mailed:
___________________________
___________________________
Is there any
message you would like to include on the gift certificate
___________________________
Credit Card to be used:
___________________________
Credit
Card Number:
___________________________
Expiration Date:
___________________________
Name & Mailing address of
credit card holder:
________________________________________________________________
________________________________________________________________
Credit Card holders authorization: Please charge my credit card
the amount noted above and mail the San Remo Restaurant gift certificate
to the address indicated above.
X_______________________________________________________________