Flatbush Food Coop Gift Certificate Order Form

To order a Coop gift certificate, please print, fill out this form, and mail or fax it to us at:

Coop Gift Certificates, Flatbush Food Coop, 1318 Cortelyou Road, Brooklyn, NY 11226-5604

Fax: (718) 284-9719

We're unable to accept Internet or phone orders, sorry.

If you can't print this order form, that's okay. Just write up the necessary information from below and mail or fax it to us. Please write legibly! Thanks.

 ____________________________________________________________________
| Name and address of person placing order:                          |
|                                                                    |
| Name: ________________________________________  Date: ___/___/___  |
|                                                                    |
| Street: ______________________________________  Apt. No. ________  |
|                                                                    |
| City: _____________________________  State ___  Zip: ______-_____  |
|                                                                    |
| Day Phone: (   ) ____-______  E-mail: ___________________________  |
|--------------------------------------------------------------------|
| Ship to: (use only if different from above). If you would like us  |
| to send the gift certificate directly to its recipient, fill in    |
| their name and address here.                                       |
|                                                                    |
| Name: ___________________________________________________________  |
|                                                                    |
| Street: ______________________________________  Apt. No. ________  |
|                                                                    |
| City: _____________________________  State ___  Zip: ______-_____  |
|                                                                    |
| Gift Certificate Message: _______________________________________  |
|--------------------------------------------------------------------|
|            Please remember that Coop Gift Certificates             |
|     MUST BE REDEEMED IN PERSON!  We don't do mail order sales,     |
|         except for our Coop T-shirts (while supplies last)         |
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| Gift Cert. Amount (please circle):   $5 $10 $15 $20 $25 $50 $100   |
|--------------------------------------------------------------------|
|                                 TOTAL AMOUNT ENCLOSED  | $    .    |
|--------------------------------------------------------------------| 
| Payment by:  ( ) Check   ( ) Money Order                           |
|              ( ) Visa    ( ) MasterCard                            |
|                                                                    |  
| Card #: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|  Exp. Date: |_|_|/|_|_|  | 
|                                                                    |   
| Name on card: __________________________________________________   |
|                                                                    |
| Cardholder's Sig.: ____________________________   Date: __/__/__   |
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| Special Instructions:                                              |
|                                                                    |
| __________________________________________________________________ | 
| We'd appreciate if you could tell us how you found our Web site:   |
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|____________________________________________________________________|