Fax or Mail Order Form

This form may be mailed or faxed to:
Jan Collins Selman Fine Art
317 Main St., Falmouth Village, MA 02540
Phone 508-457-5533  Fax 508-457-5544
(You May Also Place A Phone Order During The Gallerys' Open Hours)

Click Here To Return To Order & Shipping Page__________________________________________________________________

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__________________________________________________Sub-Total|_________|


_________________________________                 5% MA Tax|_________|


_______________________________        Shipping per Framed |_________|


_____________________________________Each Unframed @17.00  |_________|


_______________________________________________COD ($10.00)|_________|


_______________________________________________Grand Total |_________|


Name:__________________________________________
                     

Company:________________________________________________________________


Street:___________________________________________________________________

       _________________________________________________________________


City:_____________________ State:______ Zip:__________ Country:__________


Daytime Phone:_______________________ Fax:___________________________
  

    [ ]My check or Money Order (U.S. Funds Only) made out t:
				
 Jan Collins Selman Fine Art

    [ ]Purchase Order attached

    [ ]Please charge my     [ ]MasterCard  [ ]Visa  [ ] American Express


    Account #:_____________________________________Exp. Date:__________
  

    Signature:_________________________________________________________