GALLERY
Fax Order Form

mobill:  055-883345   Fax: 03-5083128
  
Name: ___________________________________________________________
 
Address: ________________________________________________________

City: _______________________ State: ________ Zipcode:___________

Daytime Phone: __________________________________________________

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ITEM         .      QUANTITY        .     PRICE
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Total Amount .                      .
of Order     .                      .
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Method of Payment  Date: _______________________________________