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Please print the form below,
fill it out, and FAX it to Carpe Diem Restaurant 704-377-7975
(Office telephone:704 377-7976). We will call you to verify credit card information
and to confirm delivery.
Credit Card Information
Type of Credit Card__________________________________________________________
(We accept American Express, Visa, Master Card, and Diner's Club)
Credit Card Number _________________________________________________________
Expiration Date_____________________________________________________________
Security Code (last 3 digits in signature space of visa/mc, 4 digits on front of amex over hologram)__________
Billing Address _____________________________________________________________
(We will send receipt to this address)
Amount:___________________________________________________________________
(We recommend the following guideline for two persons:
$100 for Dinner, depending on your guests' taste.)
Cardholder Name (Please print) _______________________________________________
Cardholder's Signature _______________________________________________________
Phone number (incl. area code) and time of day when you can be reached_____________
__________________________________________________________________________
Gift Particulars To __________________________________________________________
From _____________________________________________________________________
Message __________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Mail Certificate to __________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
We request 24 hours to prepare your custom gift certificate. To
expedite delivery, we will send your certificate via Federal Express ($15 fee
for weekdays or $30 fee for Saturdays). Please indicate weekday or Saturday delivery:
Weekday: _______ Saturday: _______ We will also deliver the certificate within
the Uptown area for a $10 fee:________ (Check here to have a messenger deliver
the certificate.)