PAYMENT FORM
To:	THAVIBU GALLERY : Fax number = + 66 2 266 5455
From:	Name:...........................................................................................................
	Address:........................................................................................................
	Postal Code:...................................................................................................
	State/City:.....................................................................................................
	Country:........................................................................................................
	Fax.no:..........................................................................................................
	Tel.no............................................................................................................
	Email:............................................................................................................
Order:	Name of Artist:................................................................................................
	Title of Artwork: ..............................................................................................
	Price of Artwork:...............................................................................................
	Cost of Shipping and Insurance:..........................................................................
	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
	Name of Cardholder:..........................................................................................
	Credit Card no.
	And, 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:............................................................................................................