Highlands Bar & Grill Gift Certificate Request Form

Print this page, complete the form, and mail or fax to

Highlands Bar & Grill

2011 11th Avenue South Birmingham, AL 35205

205.939.1400 phone                       205.939.1405 fax

Date:____________


Your Name:_________________________________ ____________________________________________


Phone:_____________________________________


Credit Card Type:____________________________ Credit Card #:_______________________________

Exp. Date:_________________


Name on Credit Card (please print):________________________________________


Credit Card Holder’s Signature:___________________________________________


What should we do with your receipt? (please circle below) mail it to me    fax a copy to me    shred it


Fax#:_____________________ Gift Certificate Amount:______________________


To:_______________________________________


From:_____________________________________

Mail Gift Certificate to (name and address please):

_________________________________________


_________________________________________


_________________________________________
Please fax a copy of the credit card to be charged with this request.