Gift Certificate Authorization Form

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308 7th Street | Glenwood Springs, CO 81601
970.945.4619 | Fax 970.928.0750
steakhouse@sopris.net
Gift Certificate Authorization Form
In order for Juicy Lucy’s Steakhouse to complete your gift certificate request, we need your signed
authorization. Please print the following form and fill out all information.
Return the signed copy by fax or mail to the number or address listed at the bottom of this form.
You may also call in a gift certificate request to 970.945.4619.
Gift Certificate For: _________________________________________________
Gift Certificate From: ________________________________________________
Name: _________________________________
Date: ______________________
Phone Number: ______________________________________________________
Credit Card Type:
VISA
MC
Name on Credit Card: ________________________________________________
Credit Card Number: _________________________________________________
Exp. Date: ______________________ CCV#
: ___________
(3-digits on back of card)
Billing Address: _______________________________________________________
__________________________________________________________________
Authorizing Signature: _________________________________________________
Special Gift Certificate Notes:
Gift Certificate Amount:
$ _________
Shipping/Handling:
$ 2.50
Total Charge:
$ _________
Mail To: _____________________________________________________________
Mailing Address: ______________________________________________________
____________________________________________________________________
Call Request In:
Mail To:
Fax Form To:
970.945.4619
308 7th Street
970.928.0750
Glenwood Springs, CO 81601

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