Gift Certificate Request Form

Print this page, fill out the form, and mail it to us along with your payment to

The Mole Hole of Portland
11787 SW Beaverton-Hillsdale Hwy.
Beaverton, OR 97005

If you have any questions or want to order by phone, call us at 1-800-626-8923

 Name:

  _____________________________________________

 Billing Address:

  _____________________________________________

 City, State, Zip

  _____________________________________________

 Phone:

  (______)______________________________________

 E-mail:

  __________________@__________________________
Gift Certificate Information:

 To:

  ______________________________________________

 From:

  ______________________________________________

 Amount:

  $_____._____

 Message:

  ______________________________________________
   ______________________________________________
Shipping Information (if different from billing name and address):

 Name:

  ______________________________________________

 Address:

  ______________________________________________

 City, State, Zip

  ______________________________________________

Payment Options: 

  

Check #:

  _________

 or

  

Credit Card Type: 

  _________

 Number:

  ______________________________________________

 Expiration Date:

  ______________________________________________

 Amount:

  $______.____

 Signed:

  _______________________________________________
  I authorize The Mole Hole of Portland to charge the amount listed above to my account.

 Date:

  _____/______/________