Fax: (403) 609-3599
    Phone: (403) 678-6088

CREDIT CARD AUTHORIZATION

_____________________________________
Contact Name
  		_____________________________________

 
____________________
Phone number
  		____________________
Fax number
 
_____________________________________
Email address
 
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     M/C    AMEX    DINERS

NAME (as it appears on the card): _____________________________________

CREDIT CARD #: ________________________________________   EXPIRY DATE: ______________

SIGNATURE: ___________________________________________

Special Instructions

To:_______________________________________

From:_____________________________________

___ 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

Thank you for choosing quarry bistro & winebar!