PERSHING SQUARE GIFT CERTIFICATE

*Please print this form, and fax to (212) 818-1248

RECIPIENTS FIRST NAME:________________________________________________________________________________

RECIPIENTS LAST NAME:_________________________________________________________________________________

NAME OF PERSON OR COMPANY ISSUING THE GIFT:__________________________________________________________

PAYMENT INFORMATION

Payment: (Pick One) Amex____ Master Card____ Visa____ Discover____ Diners____

Name as it appears on credit card:____________________________________________

Credit Card Number: ____________________________________________ Expiration Date:____/____

Amount: _____$50_____$100_____$150_____$200 _____Other Amount

Telephone Number:_____-_____-_______

Fax Number: _____-_____-_______

Recipient Information

Mail To: ___________________________________________

Address:___________________________________________

City:______________________________________________ State:____________________ Zip:_______________________

________ Will Pick up __________________________________________________Date and Time of Pick Up