Puppy Gift Certificate Order Form

Print and Mail                                                                                                                       http://keithscavaliers.tripod.com

            PUPPY GIFT CERTIFICATE ORDER FORM

                    To order your gift certificate, please enter the information below.

Recipient Name

_____________________________________

Occasion

_____________________________________

Certificate Amount

_____________________________________

--- Please circle your choice of payment ---

                                          Personal Check        Money Order        Visa       MasterCard        Discover

                       Keith: Please except my payment of $___________ for the gift certificate amount above.

                                                                    (All Orders Shipped Same Day Received)

For your convenience, you can make payment to keithloehrer@bigfork.net using PayPal.

Card# ____ ____ ____ ____     ____ ____ ____ ____    ____ ____ ____ ____    ____ ____ ____ ____

Expiration Date ______ / ______ /__________  Signature X_________________________________________

On the back side of your card, give us the last 3 digits next to your signature.   ___ ___ ___

Name: ___________________________________________________________ Date : ____ /____ /__________

Address: __________________________________________________________________________________

City: ____________________________________________________ State: ______ Zip: __________________

Home# ( _______ ) ________ - _____________                           Cell# ( ________ ) ________ - _____________

Mail Today To: Keith Loehrer   P.O. Box 334 Bigfork, MN 56628