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Steeple Gallery Coffee House Fax Form
Please fill out the form below. |
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| Date of Order: | __________________________________ |
| Your Name: | __________________________________ |
| Company Name (if applicable) : | __________________________________ |
| Phone Number (W): | __________________________________ |
| Phone Number (H): | __________________________________ |
| Email Address: | __________________________________ |
| "Bill to" Address - Street: | __________________________________ |
| City, State, Zip: | __________________________________ |
| "Ship to" Address - Street: | __________________________________ |
| City, State, Zip: | __________________________________ |
| Credit Card Information
- Card Type: Visa • M/C • Amex • Discover |
__________________________________ |
| Card Number and Exp Date (xx/xx): | __________________________________ |
| Item # 1 - Description & Price: | __________________________________ |
| Item # 1 - Artist Name: | __________________________________ |
| Item # 2 - Description & Price: | __________________________________ |
| Item # 2 - Artist Name: | __________________________________ |
| Total Purchase
Price: before shipping and applicable tax |
__________________________________ |
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Steeple Gallery Coffee House ~ 102 E. Lafayette ~ Monticello, IL ~ 61856
Hours (CST): Monday -Friday 9 -5 ~ Saturday 10 - 5 Questions? Call or E-mail Us: (217) 762-2724 or zach@steeplegallery.com |
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