|
Customer Information |
Date of
Order: ____________________________
|
|
Name:
|
_________________________________________________________
|
|
Shipping Address:
|
_________________________________________________________
|
|
City/ State/ Zip/Country:
|
_________________________________________________________
|
| Phone |
___________________________ |
|
Fax
|
___________________________
|
|
E-Mail:
|
_________________________________________________________
|
|
|
|
Billing Address:
|
(Only if different from the above
information)
|
|
Name:
|
_________________________________________________________
|
|
City/ State/ Zip/Country:
|
_________________________________________________________
|
|
Country:
|
_________________________________________________________
|
|
| Credit Card Information |
|
Credit Card:
|
[ ] MasterCard [ ] VISA [ ] AMEX
|
| Name On Card: |
_________________________________ |
| Expiration Date: |
______________ |
| Credit Card Number: |
_______________________________________________________ |
| Security Code |
_____________
|
| Signature: ________________________________________
|
Please make checks & money orders payable to: The Art Explorers Inc.
Mail Orders to: GOS TV Series DVD, c/o The Art Explorers, Inc.
500 N. Michigan Ave. Suite 300, Chicago, Illinois 60611
FAX to: (773) 743 - 3541 Phone: (312) 932-9305
Email: sales@theartexplorers.com
Note: "Security Code" is the last 3 or 4 numbers on back of card or 4 on AMEX front.
|