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   ___________