Date: _____________

From: ____________________________________

To:     ____________________________________

Mail To: ___________________________________
________________________________________

________________________________________

Gift Certificate Amount: $__________

Credit Card Type:
Visa/Mastercard __
American Express __
Diners __

Credit Card #:___________________________________

Expiration Date:______________

Your Phone: (______)__________-________________

Your Fax:      (______)__________-________________

I _____________________________________________, authorize The` Hilltop Cafe to charge my credit card for the amount of $_____________.

Authorized Signature: ________________________________