Ralph Proctor Gallery Gift Shop Order Form
Print this form, complete the order information, and mail to the address
below. You may fax your credit card order to: 1-412-731-8542
Quantity Item Price Each* Total Amount
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[______] Myrrh Necklace $18. ____________
[______] Malachite Necklace $24. ____________
[______] Cross of Agadez - small $20. ____________
[______] Cross of Agadez - large $30. ____________
[______] Dahomey Wall Hanging - small $35. ____________
[______] Dahomey Wall Hanging - medium $80. ____________
[______] Dahomey Wall Hanging - large $165. ____________
[______] Gold Weight - geometric $30. ____________
[______] Gold Weight - geometric $50. ____________
[______] Gold Weight - figure $50. ____________
[______] Gold Weight - figure $75. ____________
[______] Gold Weight - figure $150. ____________
[______] NameArt-standard ___female ___male $12. ____________
NAME:__________________________________________
[______] NameArt-African theme ___female ___male $16. ____________
NAME:__________________________________________
[______] African Art Lover's Guide to Collecting $14. ____________
[______] African Images to Color $14. ____________
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SUBTOTAL ____________
PA residents add 6% of SUBTOTAL sales tax ____________
Allegheny County residents add 1% or SUBTOTAL sales tax ____________
*all prices INCLUDE U.S. shipping and handling TOTAL ____________
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PURCHASER INFORMATION
Name_____________________________________ Phone ( ) _______________
Address__________________________________________
__________________________________________
City________________________ State__________ ZipCode/Country______________
E-mail Address____________________________________________________________
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CREDIT CARD: [ ] VISA [ ] MasterCard [ ] American Express
Cardholder Name___________________________________________________________
Account Number__________________________________ Expiration Date__________
Cardholder Signature______________________________________________________
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Make check or money order payable to Ralph Proctor Gallery
and mail to 322 North Lang Avenue
Pittsburgh, PA 15208
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Thank you for your order!