Oregon Electric Station
Gift Card Fax Form

Print out this form to order gift cards for the Oregon Electric Station Restaurant and Lounge.
Be sure to fill out all required fields, which are marked with an *.
Then fax your order to the restaurant at 541-484-6149.
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Purchaser Information

Name

Address:*

City:*

State:* Zip:*

Phone Number:* Fax Number:*

E-mail:

Credit Card Type:*

Name as it appears on your Credit Card: (if different from above)*

Credit Card Number:*

Credit Card Expiration Date:*

Dollar Amount wanted on the gift card:*

Additional information to be printed on the card:

Please send me a receipt (circle one):* YES NO

Please email me to confirm order sent. YES NO
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Recipient Information

Name:*

Address:*

City:*

Sate:* Zip:*

Please mail this gift card to (circle one):* PURCHASER RECIPIENT
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When completed, fax to: Oregon Electric Station - Fax: (541) 484-6149