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? ____________________________    
Credit card number ____________________________ Exp. ______
  Please provide copy of front and back of card with order; Ceiba will be unable to process order without copy. CID Code: _______
Full name as it appears on card ____________________________    
Billing Address ____________________________    
  ____________________________    

Billing Phone Number

Billing Email

____________________________

____________________________

    

Purchaser's signature
____________________________ 		   

Denomination of certificate:
$ _________ (minimum $25)		    
    Subtotal $ ________
Overnight service fee?     $      30.00
TOTAL CHARGED TO CARD     $ ________
       
       
       
Should Ceiba mail the certificate to the purchaser? Yes _________No___________    
Where should Ceiba mail the certificate? Name_______________________    
  Address______________________    
  ____________________________    
   
Thank you for your order, please allow one week for standard mail delivery.


CEIBA
701 14th St., NW
Washington, DC 20005
202-393-3983