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 ___________