Your details (please print):
Your name ……………………………………………………………..………

Your email address…………………………………………………………….

Confirm your email address: …………………………………………………….

Your Street Address: ……………………………………………………………

Your City ……………………………………….……………………………..

State: ………………………Postcode…………Country…………………………

Your telephone number (with locality code): …………….................……………….

Information about the painting (tick one):
..... I wish to order a painting from photo (copies of photos attached)

..... I wish to buy Painting Number : ……… Painting Name: .....................…………………...

Address to which the painting is to be sent if different to above::

Recipient name : ……………………………………….……………….…

Street Address: ……………………………………….……………….…

City : ……………………………………….……………………….….…

State: ………………………Postcode: ………Country:……………………

Payment details (cost + freight is shown in the price list for your freight destination):

I paid [Currency]: .............[Amount]:…........………… on [date]: ……….......…by

(Tick 1) (account numbers are emailed to you when you reserve a painting)
....................... direct transfer to ANZ Bank Australia
....................... direct transfer to ANZ Bank New Zealand
....................... direct transfer to AdvanceBank Germany
....................... Paypal
....................... cheque/money order (attached).

Send this form to : E Gordon Werner, 2 Pleasant Avenue, Erskineville NSW 2043, Australia
[Our Australian Business Number (ABN) is 14 668 299 854.]