Foster's Coach House Tavern
Gift Certificate Fax Form – (845) 876-0878

__________
     Date     

I, ________________________________, authorize Foster’s Coach House
                                    Print Name

Tavern to sell me __________ Gift Certificate(s) for ______________ .  I  
                                            Quantity                                                                $ Amount

authorize Foster’s Coach House Tavern to charge my  ________________;
                                                                                                     Credit Card Type
(Visa/MC)

Credit Card #: _______________________    Expiration Date: __________

I understand that the Gift Certificate(s) will be mailed to the address
indicated below and that the Gift Certificate(s) expire in one (1) year
and are non-refundable.

                                                           ______________________________
                                                                               Signature

Address:_____________________________________________________

         ________________________________________________________

         ________________________________________________________

         ________________________________________________________

Telephone: ________________________

Special Instructions: ___________________________________________

Please Fax to Fosterís Coach House Tavern at (845) 876-0878.

                                                                                                   Thank You!