ASSATEAGUE EXPLORER

ORDER FORM - GIFT CERTIFICATE

NAME: (First)____________________ (Last)_______________________ DATE: ________________

MAILING ADDRESS:________________________________________________________________

__________________________________________________________________________________

E MAIL ADDRESS: ________________________________

HOME PHONE: __________________________________

ORDER the following (Print another order form for each additional certificate.) :

The amount $_______________

Please send the gift certificate(s) to (put either email address or mailing address):

NAME: ___________________________________

E MAIL ADDRESS: _________________________________

MAILING ADDRESS: ______________________________________________________________

_________________________________________________________________________________

I am sending the payment of $_______________ by Cashier's Check or Money Order for the gift certificate.

COMMENTS:

* Please mail this form with the payment to: Assateague Explorer 6373Burton Avenue, Chincoteague, VA 23336 (make it payable to Assateague Explorer). Allow 7-14 days to receive the certificate.