729 East Third Street, OR 97128 Phone 503-474-1888 Fax 503-435-2228

Gift Certificate Order Form Date__________________________________

I, _________________________(Purchaser's Name, Please Print), authorize Bistro Maison to sell me a gift certificate for $__________(certificate value must be greater than $25.00). I authorize Bistro Maison to charge my credit card.

Below is my credit card information.

Be sure to attach a photocopy of the front and back of this card for signature verification.

Credit Card Number: __________________________________________

Type of Credit Card: __________________ Expiration Date: ___________

Card Bearer's Name: _________________________________________

Billing Address:_________________________________________________

Phone number:______________________________________________________

Card Bearer's Signature:____________________________________________________

I understand that the Gift Certificate will be mailed to the address below and I am familiar that Gift Certificates are good for one year from the date of issue and are non refundable.

Recipient Mailing Information:

Name/s:_____________________________________________________

Mailing Address:_____________________________________________________

Phone Number:_____________________________________________________

Shipping (please select an option)

____ US Postal Service First Class Mail. ($3.00/certificate shipping and handling fee will be applied and is shipped via United States Postal Service First Class Mail.)

____ Overnight shipping via Fed-X ($17.75 shipping and handling fee will be applied)

____ Next Business Day Hand Delivery in the Portland/Beaverton/Salem area ($25.00 shipping and handling fee will be applied)

Please complete this form and fax it to 503-435-2228