PAYMENT AUTHORIZATION FORM

I authorize Antoine CHAPON Art Gallery - St. Martin, FWI

To debit my credit card for the purchase of the print / original :

NAME PAINTINGS :......................................................................................................................................
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SIZE :................................................................................................................................................................
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* Please note charge for packaging, shipping by DHL and insurance :

Prints: 35 USD by shipment (one print or more)
Originals Watercolors: 50 USD by shipment + 3% (Insurance)

TOTAL AMOUNT (shipping included) :....................................USD.

SHIPPING ADDRESS:
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PHONE NUMBER: .....................................

Please, fill out this form legibly, sign and FAX it to: + 590 590 87 41 87

As soon as we receive the form, we will send you the items by DHL

For more information E-Mail : antoine@chaponartgallery.com

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