R E S T A U R A N T
Gift Certificate Order Form
To order today simply print this page, complete this form and either fax it to (202) 393-1863,
mail Gift Certificate Order Form to:
Ceiba Restaurant, 701 14th St. NW; Washington, DC 20005 (no cash, please.)
Please use one form per certificate.
| Who is purchasing the certificate? |
____________________________ |
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| Credit card number |
____________________________ |
Exp. _______________ |
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Please provide copy of front and
back of card with order; Ceiba will be unable to process order
without copy. |
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| Full name as it appears on card |
____________________________ |
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| Address |
____________________________ |
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____________________________ |
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| Phone Number |
____________________________ |
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Purchaser's signature |
____________________________ |
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Denomination of certificate: |
$ ____________ |
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Subtotal |
$ ________ |
| Overnight service fee? |
|
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$ 25.00 |
| TOTAL CHARGED TO CARD |
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$ ________ |
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| Should Ceiba mail the certificate to the purchaser? |
Yes _________No___________ |
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| Where should Ceiba mail the certificate? |
Name_______________________ |
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Address______________________ |
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____________________________ |
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| Thank you for your order, please allow one
week for standard mail delivery. |
CEIBA
701 14th St., NW
Washington, DC 20005
202-393-3983