First Name:

Last Name:

Address:

City:

State:

Zip Code:

Country:

Paintings:

Payment Option:

Card Number:

Expiration Date:

Name On Card:

Telephone Number:

Email Address:

( Please double check this or we can not confirm your order)

Additional Information:







All Sales Are Final * All charges show up from Le Image Attache

You may also print this form and fax it to (714) 638 - 4539

Or mail it to: P.O. Box 2919 Garden Grove, CA 92842 US