logo.gif (3840 bytes) USDiners.com®
6204 Everest Ct
Reno, NV 89523
Tel: 775-746-0172
http://www.usdiners.com
Order No.:
Date:
1ptrans.gif (807 bytes) Order.gif (1850 bytes) 1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes) 1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes) 1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes) 1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes) 1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes) Instructions:
To pay by Check or Money Order, please complete the form, print it, and send it with payment to: USDiners.com, 6204 Everest Ct, Reno, NV 89523. Please make your check payable to US Diners Inc.
Note: Fields in green are required.		 1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes)
  Buyer's Info:      
  Name:
  Address:
  City:
  State: Zip:  
  Phone:  
  Email:  
  Deliver to:  
  Name:
  Address:
  City:
  State: Zip:  
  Phone:  
  Email:
Quantity* Description Unit Price Total
Gift Certificate for --->#23040023
  Special Instructions: (35 words max.)
 Subtotal:
S/H:
Total:
1ptrans.gif (807 bytes) 1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes)
Payment Detail
Check
Money Order
Visa
MasterCard
Name on Card:
Card Number:
Exp. Date: Card ID:

 

  

Signature:____________

Thanks for choosing USDiners.com
Any questions? Please contact us at sales@usdiners.com

* Quantity means the number of gift certificates.
1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes)
1ptrans.gif (807 bytes)
Copyright © 2008 USDiners.com