Dining Concepts
520 Butternut Dr #8
PMB #252 Holland MI 49424
www.diningconcept.com
616 738-3087

Order Form:

Date: __________________________
Company
Company __________________________________________________________________________________
Contact Name_______________________________________________________________________________
Address___________________________________________________________________________________
City ________________________________________________State__________________ Zip______________
Phone_____________________________________________________________________________________
For Internal Use Description Cost per Certificate Quanity TOTAL
  $20 Dining Certificate $20.00    
  $25 Dining Certificate $25.00    
  $30 Dining Certificate $30.00    
  $40 Dining Certificate $40.00    
  $50 Dining Certificate $50.00    
Payment: q Check q Visa q Master Card q American Express
 
___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ __ - ___ ___ ___ ___
Credit Card Account Number
   
_____________________________________________
Cardholder's Signature		 _____________
Expiration Date
   
_____________________________________________
Cardholder's Address		  
       
_________________
City 		______________
State 		___________
Zip 		 
Total Price of Certificates  
Postage and Handling $3.99  
TOTAL  

Three Simple Ways to Order

1. Mail payment with complete order form.

2. Provide credit card information and fax to 616-738-2189.

3. Order online at:
www.diningconcept.com