ORDER FORM

Mosaic Art & Décor 460 Crooked Side Road Ashton, ON     K0A 1B0 (613) 253-8294 e-mail:  mosaicartdecor@aol.com

This form cannot be filled out on-line.  Please print, and mail completed form or copy form to a Microsoft Word document and e-mail completed form.

Customer Name:
Shipping Address:
Telephone #:
e-mail Address:

ITEM DESCRIPTION	PRICE
	______________________
Subtotal:
P.S.T. (Ontario Residents)
Shipping & Handling:
TOTAL CHARGE (Canadian $):

Indicate with an 'x'	PAYMENT METHOD	Details	Enter Information Here
	Cheque or Money Order	Make cheque or money order payable to:	Mosaic Art & Décor
	M/C	Name (as it appears on credit card):
	VISA	Credit Card #:
	AMEX	Expiry Date:
	Gift Certificate	Gift Certificate #: