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This is to authorize quarry bistro to charge to my credit card account the amount of $___________ for the purchase of _______________________________________ .
I would like it charged to the following credit card:
VISA MASTERCARD AMEX DINERS
NAME (as it appears on the card): _____________________________________
CREDIT CARD #: ________________________________________
EXPIRY DATE: _____________________
SIGNATURE: ___________________________________________
Special Instructions
___ I will pick up the Gift Certificate at quarry bistro
___ Please mail the Gift Certificate to the following address:
___________________________________________
___________________________________________
___________________________________________
Would you like a copy of the receipt?
___ I would like the receipt faxed to me
___ I would like the receipt included with the Gift Certificate
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