Fax/Mail Order Form

VIRGINIA HOUSTON ART

19 Frenchman’s Road

Oakfield, NS

Canada B2T 1A9

 

Printable Fax/Mail Order Form

 

Date: ____________________

 

Phone: ____________________ Fax: _________________ E-mail_____________________________

 

Order placed by Fax, Phone, E-mail, Regular Mail: ____________ 

 

VISA # or MC # (Circle one) _________________________________ Expiry Date:  _______________

 

 

Company or Person’s Name ___________________________________________________________

 

Mailing address: ____________________________________________________________________

 

City: _________________________________ Province/ State _______________________________

 

Postal/Zip Code: ________________________

 

Country _______________________________

 

 

Quantity                                            Description of Item                            Unit Cost        Total Cost

 

______           ________________________________________          ________        __________

 

______           ________________________________________          ________        __________

 

______           ________________________________________          ________         __________

 

______           ________________________________________        ________         __________

 

______           ________________________________________        ________         __________

 

                                                                                                                                         Subtotal _______

 

                                                                                                                      Shipping Charges _________

                                                                                                                            

                                                                                                                        Taxable Subtotal _________

 

                                                                                                                                   GST/HST _________

 

                                                                                                     Total Cost   ___________