Empire Magic Gift Certificate - Order Form

Empire Magic
99 Stratford Lane
Rochester, New York 14612-2981

Information Line ~ (585) 227-9760
(ORDERS ONLY HOTLINE) ~ 1-800-859-9166
FAX Line ~ (585) 368-9569

Use your browser's "Print" feature to print a copy of this form.

Please send an Empire Magic Gift Certificate in the amount of . . .
[__] $20 . . . . [__] $50 . . . . [__] $75 . . . . . . . . . [__] $________

Please print clearly so your Gift Certificate is prepared without error.

• To:
• Name:___________________________________________________________
• Address:__________________________________________________________
• City:______________________ State:_________ ZIP/Postal Code:____________

• This Gift is From:
• Name:___________________________________ E-mail Address:____________
• Address:__________________________________________________________
• City:______________________ State:_________ ZIP/Postal Code:____________
• Telephone (______) ______ - ______________ Date:______________________

Please complete this section if paying by credit card

[__] Mastercard . . . . . . . . . . . . [__] Visa . . . . . . . . . . . . [__] Discover
Card Number:_______________________________ Expiration Date:_______________
Print card holder's name as it appears on the card:_______________________________
Card Holder's Signature:___________________________________________________

GIFT CERTIFICATE INFORMATION

Copyright © 2005 by Empire Magic. All Rights Reserved.