YOU NEED TO PRINT THIS FORM

 

INFORMATION REQUESTED (CHECK ONE)

___________ IDENTIFICATION  @ $25.00 each (plus app. tax)

________REPLACEMENT VALUE @ $50.00 each (plus app. tax)

________ LETTER OF AUTHENTICITY @ $50.00 (each plus app. tax)

 

TITLE (if known)________________________________________________

Medium____________________________Year________________________

Image Size:________________________Paper Size:____________________

Number in Edition (if limited)______________________

PHOTOS ATTACHED___________

 

NAME________________________________________________________

ADDRESS_____________________________________________________

CITY/STATE_______________________________________ZIP________

PHONE_______________________CELL____________________________

E-MAIL______________________________________

CREDIT CARD________________________________EXP_____

SIGNATURE___________________________________________

MAIL or EMAIL TO:

  PENA STUDIO GALLERY             

  23A ARROYO NAMBE               

   SANTA FE, NM  87506                 

   penagallery@earthlink.net             

 

 

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