GIFT CERTIFICATE ORDER FORM

PURCHASED BY:

First Name Last Name

Street Address City

State Zip

Email Address (*Required Field- Need so I can send confirmation)

PAYMENT METHOD:

Secure Server

American Express Visa Mastercard Discover

Credit Card Number Expiration (example- 07/02)

TYPE OF GIFT CERTIFICATE:

Christmas Certificate Regular Certificate

Gift Certificate Amount:

GIFT CERTIFICATE PURCHASED FOR:

Recipient name on certificate:

MAIL CERTIFICATE TO:

Email (will print in color if using a color printer)

Purchaser-address above

Address Below

First Name Last Name

Street Address: City

State Zip

HOW DID YOU HEAR ABOUT MICHELLE DUBE?:

Southland Golf Magazine Website California Golf Magazine Friend Brochure

Tijeras Creek Driving Range Other