Reference : _________________________________________
Painting : _________________________________________
Size : _________________________________________
Price : _________________________________________Frame : _________________________________________
NOTE: When ordering 'Your-Own-Portrait-by-van-Gogh', please do not forget to
send us the picture you want reproduced by mail !!
(for mailing address, click the 'Contact' button after faxing this form)
First Name : _________________________________________
Last Name : _________________________________________
E-mail : _________________________________________
Telephone : _________________________________________
Fax : _________________________________________
NOTE: We cannot ship to Post Office Boxes, we must have a street address!
Shipping Address 1 : _________________________________________
Shipping Address 2 : _________________________________________
City : _________________________________________
State / Country : _________________________________________
Postal Code : _________________________________________
Below please enter Cardholder's Address exactly as shown on Credit Card statement!
Payment Option : Credit Card / International Money Order / Personal Check / Cash
Spread Payment : Yes / No
Credit Card Type : Visa / MastercardEurocard / American Express / Diners
Credit Card Number : _________________________________________
Expiration Date : _____ / _____ / _____
Name of Cardholder : _________________________________________ (as shown on Card)
Address of C.holder: _________________________________________City : _________________________________________
State : _________________________________________
Zip/Postcode : _________________________________________
Country : _________________________________________
Signature Panel Code : _________________________________________
(The last 3 digits on the back of your card)