| Date |
___________________________________ |
| Telephone Number |
___________________________________ |
| Cardholder's Name |
___________________________________ |
| |
VISA MasterCard |
| Credit Card # |
___________________________________ |
| Expiration Date |
_________/_________ |
| Amount |
$__________________ |
| Delivery Charge |
$ 2.00 by Canada Post |
| Total |
$__________________ |
| Signature |
___________________________________ |
| Gift Service/ Day Spa |
___________________________________ |
| ______________________ |
___________________________________ |
| ______________________ |
___________________________________ |
| To |
___________________________________ |
| From |
___________________________________ |
| Message |
___________________________________ |
| Address to be sent |
___________________________________ |
| |
___________________________________ |
| |
___________________________________ |