von Schroeder
F I N
E A R
T S
________________________________________________________________________________________________________________________________
agent@vonschroederfinearts.com.au tell: 0419 335 735 www.vonschroederfinearts.com.au
PURCHASE
SUBMISSION
NAME:……………………………..………………………
ADDRESS:………………………..………………………
………..………………..……………………..
CONTACT
NUMBER:……………..…………….………
EMAIL
ADDRESS:………………..…………….……….
Artwork details:………………………………..………….……….
Price:………………..……... Date:…………………….…….
Please
complete this form and e(mail) it to us.
CREDIT
CARD AUTHORISATION
I
.................………………………….………..authorise von Schroeder Fine Arts
to charge the amount of AUD S…….………..……… to
my credit card
VISA*
MASTER CARD*
AMEX*
NUMBER:________/________/________/________
EXPIRY
DATE:(mm/yy) ________/________
CCV:(3
digits for VISA/MASTER, 4 digits for AMEX) ________
CARD HOLDER SIGNATURE:………………………………………………………………………..