GO BACKGO BACKO R D E R - F O R M
| SHIP TO | BILL TO (USE ONLY IF DIFFERENT) |
| NAME | NAME | ||
| ADDRESS 1 | ADDRESS | ||
| CITY/STATE/ZIP | CITY/STATE/ZIP |
PAYMENT BY
| MONEY ORDER | AMOUNT ENCLOSED | $ | |
| CREDIT CARD | CARD TYPE | VISA / MasterCard | |
| CARD NUMBER | |||
| EXPIRATION DATE | DATE ORDERED | ____/_____/_____ | |
| ITEM NO. | PAINTING TITLE/ | STUDIO NAME | TOTAL AMOUNT |
|
|
| SUBTOTAL |
|
| SHIPPING AND HANDLING | |
| SC RESIDENTS ONLY ADD 5% TAX | |
| TOTAL DUE |
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SIGNATURE