Mr Mrs Ms
Surname : Given Name :

Company : Job Title :

Address1 :
Address2 :
Zip/Post Code : City :
State/Province: Country :

Activity :

Tel : Fax : E-mail :
Mobile Tel : Company Web :

I order

Painting title:	Item Number	Artist Name	Price in US Dollars
Sub Total US Dollars	US $
Bank transfer charge	US $ does not apply to Credit Card
TOTAL AMOUNT	US $

Please charge my credit card :

Visa

Eurocard/Mastercard

Credit Card Number : Expiration date :

Name as appears on card :