ORDERING BY MAIL

Date: ________________

Mr. __
Name: Ms. __ ________________________________________________

Address: Street: ________________________________________________

City: ________________________________________________
State: ______________________________ Zip: ___________

Phone #: Home: (_________) __________ - _______________________
Other: (_________) __________ - _______________________

Email: (Optional): ______________________________________________

I AM PLACING MY ORDER FOR:

Title: ________________________________________________________
Artist: ________________________________________________________
Item Number: ____________________

Price: $ __________________
(If shipped to PA address, add 7% sales tax) __________________
TOTAL: $ __________________

METHOD OF PAYMENT:

___ Check (Payable to Renaissance Gallery)
___ Credit Card __ Visa __ Master Card __ Am Express __ Discover
Card Number: ____________________________________________
Expiration date: ____________________________________________
Name as it appears on card: ____________________________________________

SHIPPING ADDRESS: __ Same as above

Mr. __
Name: Ms. __ ____________________________________________________
Address: Street: ____________________________________________________
City: ____________________________________________________
State: ________________________________ Zip: ______________

Allow 7 - 10 days from receipt of order to shipping.

Thank you for your business.