Vincent Art Gallery
MAIL ORDER FORM

Please print, fill out and mail your order

Reference     : _________________________________________

Painting      : _________________________________________

Size          : _________________________________________

Price         : _________________________________________

Frame         : _________________________________________

NOTE: When ordering 'Your-own-Portrait-by-van-Gogh', please do not forget

      to include the picture you want reproduced!

Your details

First Name    : _________________________________________

Last Name     : _________________________________________

E-mail        : _________________________________________

Telephone     : _________________________________________

Fax           : _________________________________________

Shipping address

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        : _________________________________________

Method of payment (all fields are required)

        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 : _________________________________________

Address of C.holder: ________________________________________

City                : ________________________________________

Zip/Postcode       : ________________________________________

State               : ________________________________________

Country             : ________________________________________

Please mail this form to:

Vincent Art Gallery
Hoge Slagen 303
5233 SL 's-Hertogenbosch
The Netherlands