Name: __________________________________________ 

Street Address: ________________________________ 

City: __________________________________________ 

State/District: ________________________________

Postal/Zip code: _______________________________

Country: _______________________________________

E-Mail Address:_________________________________

Phone number (daytime): ________________________ 

Phone number (evening): ________________________ 

Fax number: ____________________________________ 

Artist                  Title                   Price

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Shipping: [ ]Surface [ ]Air [ ]Postage          ______

8.75% sales tax (for California residents only) ______ 

                                         Total  ______