BREEWOOD ONLINE GALLERY SHOP ... MAIL ORDER FORM
Payment by cheque or card
MAIL TO:
 Mail Orders, Breewood Gallery, 167 The Mall, Leura, NSW 2780

NAME
FULL ADDRESS
CREDIT CARD TYPE	(Circle one)              VISA              MASTERCARD              BANKCARD
CARD   NUMBER	EXPIRY DATE:
PHONE (with   area code)
FAX (with   area code)

Details of Cheque

DRAWER:	NUMBER:
BANK:	AMOUNT: $
SIGNED:	DATE:

Purchase Details

ITEM		PRICE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Postage will be charged at cost
TOTAL $