the art of CHellman - request form

Please check the items you wish to inquire about:

		Bamboo1				Gnarled Tree
		Dragon Head				Cloud Mountain1
		Cloud Mountain2				Cloud Mountain3
		SeaScape

Please indicate your choice: poster print ($24.95) signed, numbered lithograph ($3000 to $5000) original ($10,000)
	I WISH TO COMMISSION A WORK		PLEASE DESCRIBE THE NATURE OF THE COMMISSIONED WORK YOU DESIRE.

BILLING INFORMATION
*PAYMENT CHOICE:	ESCROW		CASHIER'S CHECK		MONEY ORDER

SHIPPING INFORMATION Information you provide is kept strictly confidential.
*Recipients Name
*Street address
Address (cont.)
*City
*State/Province
*Zip/Postal code
*Country

PLEASE PROVIDE THE FOLLOWING CONTACT INFORMATION

*First name
Middle initial
*Last name
*E-mail
*Retype E-mail
Work Phone
Home Phone
FAX
Fill in this section only if the information is different than SHIPPING information
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country