ORDER FORM

NAME _________________________________________________

ADDRESS _____________________________________________

CITY _______________________ STATE _______ ZIP __________

TEL # ________________________________________

ENCLOSED IS MY CHECK / MONEY ORDER FOR $50.00.

I HEREBY REQUEST THAT A COPY OF PORTRAIT DEPICTING SM1 DOUGLAS A. MUNRO BE RESERVED FOR ME. ENCLOSED ARE NECESSARY FUNDS AS REQUIRED TO COMPLETE THIS ACTION. I UNDERSTAND THAT SHOULD THIS PROJECT NOT RECEIVE A REQUEST FOR A MINIMUM OF 250 COPIES THAT FUNDS WILL BE RETURNED BY: