PURCHASE ORDER: LITHOGRAPHS by LÉONEL JULES
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(Print)


Your name: ___________________________________________________

E-mail address: ______________________________________________

Address: _____________________________________________________

City: ________________________________________________________

Province/State: ______________________________________________

Postal Code: __________________  Country: ____________________

Telephone: ____________________  Fax: ________________________



Name of Lithograph: __________________________________________

Unit price: ______________

Quantity: ___________  

Shipping and Handling: ______________


Total Price: ___________________________


Method of payment:

   [ ] Check (in Canadian or American funds)
   [ ] Money Order
   [ ] Visa   [ ] MasterCard

         Credit Card No:   ___________________________

         Expiration date:  ___________________________


Please make your check or money order payable to:
 

Visicom Média inc.
6200 Taschereau, Suite 401
LonGueuil-Brossard
Qc, Canada, J4W 3J8
Fax: (514) 672-9586


Signature: _________________________   Date: __________________