Date: _____________

From: ____________________________________

To:     ____________________________________

Mail To^†: _______________________________
________________________________________
________________________________________

^†Please specify the address to whom the gift certificate will be mailed.

Gift Certificate Amount: $__________
Total:                             $__________

Credit Card Type:
__ Visa/Mastercard
__ American Express
__ Diners

Credit Card #: _____________________________________
Expiration Date: ______________
Zip Code: ____________________

Phone: ______-__________-____________

Fax:     ______-__________-____________

I _____________________________________________, authorize FoxFire Restaurant to charge my credit card for the amount of $_____________.

Authorized Signature: ________________________________