*Your Name: *E-mail:\
*Address:
*City: *State: AK AL AR AZ CA CO CT DE FL GA HA IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY *Zip:
*Contact Phone Numbers: (Day):

                                       (Evening):

*Gift Certificate Amount: $ 50.00 60.00 70.00 80.00 90.00 100.00 150.00 200.00 Other If Other:

Gift Certificate sent to: (you can fill out the To: and From: information on the gift certificate if you want the certificate sent to you, but we do need to know the information for our tracking purposes, ie. in case the certificate gets misplaced)
*To Name:

*From:       

*Sent to Address: Same address as above

*Pay for with: Credit Card Check

WE WILL CONTACT YOU FOR YOUR CREDIT CARD NUMBER
(DO NOT INCLUDE ON THIS FORM ! ! !)

Mail checks to:

Jakes Fine Dining
677 Main St.
Deadwood, SD 57732