The Gilded Otter Faxable
Order Form		 HOME PAGE

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Simply fill out this form (via keyboard, or, after printing, ball-point pen)
print this form, then FAX it to the Gilded Otter at 845-256-0955
Specify quantity & value          $5 x Quantity
of certificate(s) ordered:        $10 x Quantity
$25 x Quantity
$50 x Quantity		 = subtotal
= subtotal
= subtotal
= subtotal
GRAND TOTAL: $    << UPDATE TOTAL

Payment Information:
  MC #   VISA # 
(e.g. 1111-2222-3333-4444)
Name as it appears on the card:
Expiration Date (e.g. 03/05):
Telephone Number (e.g.123-456-7890):
Signature:  ________________________

Send Certificate(s) via U.S. Mail To:
Recipient's Name:
Street Address:
Address line 2:
City, State Code, ZIP:
Inscription on certificate, if any:  
info@GildedOtter.com Fax 845-256-0955
Voice 845-256-1700		 www.GildedOtter.com