ORDER FORM

To:		ART AT PLAY
		114/5 Silom soi 4
		Bangkok
		THAILAND
Fax Number:		+66 2 632 7923
From:	Name	_________________________________________
	Address	_________________________________________
	City / State	_________________________________________
	Postal Code	_________________________________________
	Country	_________________________________________
	Fax	_________________________________________
	Phone	_________________________________________
	Email	_________________________________________
Order:	Name of Artist	_________________________________________
	Title of Artwork	_________________________________________
	Price of work	_________________________________________
	Shipping	_________________________________________
	Insurance	_________________________________________
	Total	_________________________________________
Payment:	[  ]	Transfer funds to Bank
	Credit Card
	I authorize ART AT PLAY to charge my
	[  ]	American Express
	Name of cardholder	_________________________________________
	Credit card number	_________________________________________
	4 digit code (above number)	_________________________________________
	Expiry date	_________________________________________
	Total	_________________________________________
	Cardholder's Signature	_________________________________________
	Date	_________________________________________

Please complete this form in CAPITAL letters and send it by fax or mail to the address above

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