(631) 758-7640

Reservations

655-08 Montauk Hway • Patchogue • New York

Gift Certificate Request Form

1.  Gift Certificate Information (to be printed on the gift certificate)

Amount: $

To (i.e., recipient names):

Message (100 characters max):

From (i.e., gift certificate donor names):

2.  Payment Information (Mastercard | Visa only)

Credit Card Number:

Expiration Date:

Name On Card:

3.  Mailing Information

Name:

Address:

4.  Contact Information (in case of any problems)

Contact name:

Contact email:

Contact telephone: