Dinner & Date Order Form
   
Purchaser' s Information
Full Name *
Email Address *
Company
Phone (Home) *
Phone (Work)
Phone (Cell)
Fax
Address *
City *
State *
Zip Code *
   
Restaurant Chosen   
Gift Certificate Amount
No. of Gift Certificates
   
Restaurant Chosen   
Gift Certificate Amount
No. of Gift Certificates
   
Restaurant Chosen   
Gift Certificate Amount
No. of Gift Certificates
   
Restaurant Chosen   
Gift Certificate Amount
No. of Gift Certificates
   
Restaurant Chosen   
Gift Certificate Amount
No. of Gift Certificates
   
Limo Service Yes No
$80 per hour Weekend –(4 hour minimum)
$80 per hour Weekday – (3 hour minimum)
   
Flowers Yes No
   
Shipping Information
Same as above or if different fill out following form-
Recipient Information
Full Name *
Email Address *
Company
Phone (Home) *
Phone (Work)
Phone (Cell)
Fax
Address *
City *
State *
Zip Code *
   
Ken Caryl Concierge Service Fee * : $25 per order
Same Day Service Request * Yes No ($45 extra charge per order)
* Same day service is if gift certificates are needed in under 24 hours, they would then be personally hand delivered to purchaser or recipient.
Total Amount Due :  
   
Payment Information
Credit Card Number
Credit Card Expiration Date
Security Code on Card
Date of Purchase
   
Disclaimer  

** Tip is not included in Gift Certificate purchases / prices.**
** Allow 2 to 4 business days for completion of service for mail out.**
** If same day service (under 24 hours) is requested it will be personally hand delivered at an additional charge of $45.**

Ken Caryl Concierge wants to personally thank-you for your purchase. We hope that you enjoy your Dinner & Date!

 


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