| Please
Enter the requested information below and than mail
to :
Atlantic City Bar & Grill
104 S. Raleigh Avenue
Atantic City , NJ 08401
How many gift certificates do you wish to purchase?
_____________
What amount do you want the gift certificates to be
($10, $25, $50, $100)
If you want the gift certificates to be in various amounts,
please specify? ______________________________________________________
______________________________________________________
First Name: _____________________
Last Name: _____________________
Phone # : ______________ E-mail: __________________________
Street Address 1: ________________________________________
Street Address 2: ________________________________________
Town/City: _____________________________________________
State: _____ Zipcode: __________
Credit
Card Info
Credit Card (circle One): VISA or MASTERCARD
Credit Card # : _______________________
expiration date: * YYYY: ________*
MM: ______DD: ______
Additional Info (enter below):
______________________________________________________
______________________________________________________ |
