Steelhead Brewing Company
Gift Certificate Order Form

Please print off this form, fill it in, and then Fax it to:

Eugene Fax: 541-342-5338.
Burlingame Fax: 650-344-6097
Irvine Fax: 949-509-2977

Please allow one week to receive your Gift Certificate in the mail. NOTE: No cash is given on change due. Please use up your Gift Certificate in one visit.

Name on Credit Card: ______________________________________________

Company Name if also on Credit Card: _________________________________

Credit Card Billing Address: __________________________________________

City: ________________________ State: ______________ Zip: ____________

Credit Card Type (circle one): Visa / MasterCard / AmEx

Credit Card Number: ________________________________________________

Expiration Date: ________________ Amount of Gift Certif: $_________________

Phone number (in case we have questions): _(_________)__________________

E-mail Address (if we can't reach you by phone): __________________________
(We promise not to e-mail or call unless we have problems with this order.)

Do you need a receipt sent to your billing address? (circle one): Yes / No

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Gift Giver's Name: __________________________________________________

Recipient's Name: __________________________________________________

Ship To Address:

Name: ___________________________________________________________

Address: _________________________________________________________

City: ________________________ State: _______________ Zip: ____________

Optional Message: _________________________________________________

Please print off this form, fill it in, and then Fax it to:

Eugene Fax: 541-342-5338.
Burlingame Fax: 650-344-6097
Irvine Fax: 949-509-2977