Amount
Purchaser  Name
Business Name
Street Address
Address (cont.)
City
State
ZIP
Daytime Phone
E-mail (required)

Payment Method:
American Express VISA MasterCard Diners Club

Credit Card Number:

Expiration Date: DD-MM-YY

Issue Gift Certificate To: (Name of Recipient)
 

Mail Gift Certificate To:
 (Leave blank if same as purchaser)

Name
Business Name
Street Address
Address (cont.)
City
State
ZIP

Special Instructions:

There is no additional or extra charge for standard First Class Mail delivery. Please request FedEx, Priority Mail or other special services using Special Instructions section above.

Any questions about purchasing a Gift Certificate may be directed to Levana Restaurant at info@levana.com or call us at (212) 877-8457.

If you prefer, you may print a printer-friendly version of this page, sign and fax the completed form to (212) 595-7522, or mail it in with your check or money order in the appropriate amount. Mail to:

LEVANA RESTAURANT
141 West 69th St.
New York, NY 10023

For security purposes and to protect your personal information, please enter in the box below the letters you see in this image: 

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