Bleu Gift Card Request

Request received by: _____________________ Date of Request: ___________________

Amount of Gift card: _____________________________________________________

Purchaser Name: _________________________________________________________

Purchaser Phone: _________________________________________________________

Recipient Name: _________________________________________________________

Recipient Phone #:________________________________________________________

Address Card to be sent to: _________________________________________________

________________________________________________________________________

________________________________________________________________________

Card must arrive no later than: _______________________________________________

Message if any :__________________________________________________________

Additional Charges for expediting card: _______________________________________

Credit Card information: Type: __________________ Exp date :__________________

Number: ________________________________________________________________

Name on credit card: _____________________________________________________

Total charge to card :______________________________________________________

Request sent to? :_________________________ Fax or email_____________________

Request processed by:______________________ Date card sent:___________________