Fax Order Form

SlimGutGallery.com
RR#2, Box 1940 McAlisterville, Pa. 17049
Telephone - (717) 463-3384
E-Mail: mikes@slimgutgallery.com

Ship To

Name:

Address:

City:

State: Zip:

Phone Number Day:

Phone Number Night:

Fax Number:

Items Ordered

Item Number

Description/Name of Artwork

Price

Merchandise Total

Shipping, Handling, and Insurance (Add $10.00 per Print)

Pennsylvania residents add 6% sales tax

Total

Method of Payment

Visa
Master Card
Check Enclosed

Account Number: Exp. Date:

Print Name Exactly as it appears on the Credit Card: Month\Year

Signature:

Ship To
Name:
Address:
City:
State:		Zip:
Phone Number Day:
Phone Number Night:
Fax Number:

Item Number		Description/Name of Artwork	Price
Items Ordered



Merchandise Total
Shipping, Handling, and Insurance (Add $10.00 per Print)
Pennsylvania residents add 6% sales tax
		Total

Method of Payment
Visa Master Card Check Enclosed
Account Number:	Exp. Date:
Print Name Exactly as it appears on the Credit Card:	Month\Year
Signature: