Fortune Art Gallery
 230 West, 200 South, Suite 2112, Salt Lake City, UT 84101
Phone: (801) 359-6188,  Fax: (775) 249-6996

Please print and fill out the following order form, and fax your order to  (775) 249-6996. 

Customer Information:

Name:  
_____________________________________

 Email:  
_____________________________________

Phone: 
_____________________________________

 Fax: 
_____________________________________
Shipping Address:  
__________________________________________________________________________________

   
Order Information:
Title of Art:
_____________________________________		 Artist: 
_____________________________________
Unit Price:
_____________________________________		 Quantity:
_____________________________________
Title of Art:
_____________________________________		 Artist: 
_____________________________________
Unit Price:
_____________________________________		 Quantity:
_____________________________________
Title of Art:
_____________________________________		 Artist: 
_____________________________________
Unit Price:
_____________________________________		 Quantity:
_____________________________________
Subtotal:
_____________________________________		 Sales Tax:(6.6% for Utah Residence only)
_____________________________________
Shipping & Handling:
(Add 10% of Subtotal) ___________________ 		Total:
_____________________________________
    
Credit Card Information: 
___ VISA       ___ MasterCard Name On Card:  
_____________________________________
Card Number:  
_____________________________________		 Expiration Date:
_____________________________________
Billing Address:
__________________________________________________________________________________
   
Signature:
_____________________________________		 Date: 
_____________________________________

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