ORDER - PAYMENT FORM

To:	THAVIBU GALLERY
	The Silom Galleria Building, Suite 308
	919/1 Silom Rd., Bangkok 10500
	THAILAND
Fax No.	+ 662 266 5455
From:	Name:.........................................................................................................................
	Address:......................................................................................................................
	Postal Code:................................................................................................................
	State/City:....................................................................................................................
	Country:.......................................................................................................................
	Fax No:.......................................................................................................................
	Tel..............................................................................................................................
	E-mail: .........................................................................................................................
Order:	Name of Artist:..............................................................................................................
	Title of Artwork: ...........................................................................................................
	Price of Artwork:..........................................................................................................
	Cost of Shipping and Insurance (see information on previous page):................................
	Total Costs:..................................................................................................................
Conditions:	Art works which are damaged upon arrival may be returned to Thavibu Gallery
	and the amount paid will be returned to the customer.
	Paintings will be sent by courier (DHL) service if other mode of transport
	has not been indicated.
Payment	[ ] Transfer of Money (bank to bank)
options:
	[ ] Credit Card
	I authorize Thavibu Gallery to charge my
	[ ] AMERICAN EXPRESS   [ ] VISA   [ ] MASTER CARD   [ ] JCB   [ ] SCB CARD
	Name of Cardholder:...................................................................................................
	Credit Card no.
	The last three digits of the seven digit number on the signature panel at the back
	of my VISA or MASTER CARD are:
	Or, the four digits on the front panel above the card number
	of my AMEX card are:
	Expiry Date:..................................................................................................................
	Total Amount, Including Added Mailing Costs (in US$):................................................
	Cardholder's Signature:..............................................................................................
	Date:..........................................................................................................................
	Please complete this form and send it, by fax or mail, the order form fully
	completed in capital letters to the address above