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