BBIM Gift Certificate Order Form

To order one or more BBIM Gift Certificates, print out this order form, complete it, and send it and your check or credit card information to the address at the bottom of the form. We will mail you the BBIM Gift Certificate(s) as soon as we receive the order!

Your Name(s):
__________________________________________________________________

Address:
__________________________________________________________________

Address 2:
__________________________________________________________________

City:
__________________________________________________________________

State & Zip:
__________________________________________________________________

Phone: _______________________________________________________

($50 minimum per certificate; certificates are issued in $50 or $100 values only. When your order exceeds $100 we provide multiple certificates for $50 or $100 - for example, for a $300 order we will provide three $100 certificates.)

Add processing fee: $5 Total Amount: $_________________________ 
Make check to "BBIM" or fill in credit card number (MC/VISA or Discover only!) and sign below

Card number: __________________________________________________________ Expiration Date: __________________

3 digit verification number_____________

I agree to pay the above amount in accordance with my cardholder's agreement. Signature: _________________________________________________________

Amount of first certificate: $________________ ($50 minimum)

Recipient(s) name(s): _______________________________________________________________
Do you want to fill in the recipient's name yourself? Yes No

Donor's
Name(s):_______________________________________________________

Do you want to fill in the donor's name yourself? Yes No

Where do you want the BBIM Gift Certificate(s) sent?
(complete name & address below unless you want it sent to you).

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

On the reverse or a separate sheet, please provide the above information for any additional BBIM Gift Certificates you are ordering.

Mail to:
BBIM Gift Certificate (ww)
301 S. Cottage Grove Ave
Kirksville, MO
63501