Send Certificate to:  Recipient            Buyer                          

Cash Value of the Certificate:   $ 20.00 $ 25.00 $ 30.00 $ 35.00 $ 40.00 $ 45.00 $ 50.00 $ 55.00 $ 60.00 $ 65.00 $ 70.00 $ 75.00 $ 80.00 $ 90.00 $ 100.00

Recipient's Information

Recipient's Name                             Recipient's Address               

Recipient's City             Recipient's State & Zip code                          

Recipient's Phone                                    Recipient's E-mail        

Buyer's Information

Buyer's Name                             Buyer's Address                             

Buyer's City                           Buyer's State & Zip code                                                      

Buyer's Phone                                    Buyer's E-mail                   

Credit Card Information  (Your credit card information relates only to this particular transaction and is kept confidential by Deerfield Country Club and its banking institutions.)

                    Credit Card Number:                 

                    Type of Card:                        Visa Master Card Discover Card American Express

                    Expiration Date                      January February March April May June July August September October November December /               2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

By submitting this form, I authorize the Deerfield Country Club to charge my account in the amount authorized and agree to pay that amount in accordance with my card holder agreement.