by Peter Robson
Please complete and fax, or mail this order form to:
Entropic Fine Art Inc.
5929 Clements Rd.
Duncan, B.C. V9L 6J7
CANADA
Phone: 250-701-9366
1-866-806-6227
Fax: 250-701-9979
I would like to order:
# Copies Total Amount Limited Edition Print ________ X $200.00 Cdn. ____________ Shipping Charges Extra Method of Payment: Name: ________________________________________ Address: ________________________________________ ________________________________________ Phone: ( )_____-________ Fax: ( )_____-________ Master Card _________________________________ Expiry Date:____________ Visa _________________________________ Expiry Date:____________ Amex _________________________________ Expiry Date:____________ JCB Cards _________________________________ Expiry Date:____________ Signature: ___________________________________ Cheques payable to Southlake Regional Health Centre Foundation