Beaux-Artes: Fax/Mail Order Form

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Purchase Order Form

Beaux-Artes
1012 South Creek View
Churchton, MD 20733

(410)-867-0790 or
(310)-855-4244

FAX: 410-867-8004

Order Date: ________________

Order Number: ________________


Bill To:		Ship To:	(if different than "Bill To")
Name:	____________________________	Name:	____________________________
Address:	____________________________ ____________________________	Address:	____________________________ ____________________________
City:	____________________________	City:	____________________________
State:	________ ZIPCD: _____________	State:	________ ZIPCD: ______________
Phone:	___________E-Mail: ___________	Phone	___________E-Mail: ____________

Method of Payment: VISA ____ MasterCard ____ Discover ____ AMEX _____Check ____

Credit Card No:_____________________ Expiration Date: _____-_____ Security Code: _____

Cardholder Name (please print):_____________________________________

Signature:__________________________ Daytime Phone: ______________


Products Ordered
Qty	Style	Part #	Finish	Price	Total
____	________________	__________	_________________	__________	_________
____	________________	__________	_________________	__________	_________
____	________________	__________	_________________	__________	_________
____	________________	__________	_________________	__________	_________
____	________________	__________	_________________	__________	_________
____	________________	__________	_________________	__________	_________
				Order Total	_________

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