TEL: 310 388-1888 FAX: 305 751 0040 GIFT CERTIFICATE CREDIT CARD AUTHORIZATION FORM Date: _______________ I, ___________________ hereby authorize Barton G. The Restaurant – Los Angeles to charge my credit card # __________________________________ Expiration date: ____________ Cardholder Name – (Who the Gift is From): ________________________________ In the Name of: (Who the Gift is For): _____________________________________ In the amount of: _____________________________________________________ Billing Address of Card: _______________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Telephone #: _____________________Picture State I.D.#: ________________________ Cardholders Signature:_____________________________________________________ Visa, MasterCard, American Express, Diners & Discover accepted IMPORTANT: A CLEAR COPY OF THE CREDIT CARD, BOTH FRONT AND BACK MUST BE ATTACHED, ALONG WITH A COPY OF PHOTO I.D. FRONT AND BACK PLEASE FAX THIS FORM BACK TO BARTON G. THE RESTAURANT AT 305-7510040 OR E-MAIL TO [email protected] Please Mail Gift Certificate to: _________________________ _________________________ _________________________
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