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If you would like to buy a gift certificate, please complete the following form:
* First Name
* Last Name
Company Name
Billing Address:
* Address 1
Address 2
* City
* State
* Zip
* E-mail
*    Day Time Phone Number
* Gift Certificate Amount $
($50.00 minimum; $500.00 maximum)
Quantity of Gift Certificates
Name on Gift Certificate
(if more than one certificate, separate names with a comma)
Name of person giving the Gift Certificate
I will pick up my gift certificate at Chakra Restaurant

I would like you to mail my Gift Certificate for an additional fee of $5.
(Note: Shipping information will be completed at checkout. Gift Certificates can only be mailed to one location per order (multiple gift certificates can be included in one order). If you need gift certificates mailed to more than one address, please call Dorothy at 201-556-1530).

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