Austen Gallery
Postal Mail / Fax Order Form

Customer name    _________________________

Customer email    _________________________

Customer phone    _________________________

Ship to:   

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 Product Name                            Quantity   x   Price      =  Extended Price


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                                                                        Sub-total       _____.___

                                                                        Shipping*      _____.___

                                                                        Total            _____.___

*By submitting this form with the signature below, buyer agrees to be responsible for actual shipping costs which will be calculated at the time of shipping.  Mail or fax to Austen Gallery.  Submit questions to info@austengallery.com.

Credit Card Type (circle one) :  Visa     MasterCard    

Name On Card:  ______________________________________________

Billing Address:  ______________________________________________

Credit Card Number:  ______________________________________________

Expiration Date: _____/_____  CVV: _____

Signature: ______________________________________________