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PAYMENT
AUTHORIZATION FORM
I authorize
Atelier des Tropismes Gallery - St. Martin, FWI
To debit my
credit card for the purchase of the print / original
:
NAME PAINTINGS
:......................................................................................................................................
.........................................................................................................................................................................
* Please note
charge for packaging, shipping by DHL,FEDEX,UPS and
insurance :
Prints: 40 USD by
shipment (one print or more)
Originals : An
estimate will be done + 3% (Insurance)
TOTAL AMOUNT
(shipping included)
:....................................USD.
Card Type
............................................
(VISA, MASTERCARD,AMEX
or DISCOVER)
Name on Card:
.................................................
Card Number:
/...../...../...../...../
/...../...../...../...../ /...../...../...../...../
/...../...../...../...../
Expiration Date:
(MM/yy) ............./...............
Signature of
Cardholder :
SHIPPING
ADDRESS:
..................................................................................................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
PHONE NUMBER:
.....................................
EMAIL
ADDRESS:.................................................................................................
Please, fill out
this form legibly, sign and FAX it to: + 590 590 29 10
60 ,or email it to the address below
www.paul.elliott@thuleau.com
As soon as we receive the form, we will ship you the items
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