| Mail completed form to: | Susan Kathleen Black Foundation, Inc.
Attn: Merchandise P.O. Box 235 Lake George, CO 80827 |
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| GICLEE PRINTS: | Price | Quantity | Size | Total |
| Iris | ||||
| Rose Garden | ||||
| Eagke Watch | ||||
| Among the Elephants | ||||
| On the Rock | ||||
| Gone Fishing | ||||
| Wedding Rose | ||||
| Book: | Price | Quantity | Total | |
| Susan K. Black An Artistic Heart | $35 | |||
| (add $15 each for prints, $5 each for book) shipping & handling | ||||
| Total Due: | ||||
| Shipping Information: | ||||
| Name: | Daytime Phone: | |||
| Address: | Nighttime Phone: | |||
| City: | State: | Zip: | Email: | |
| Method of payment: | ||||
| Check Enclosed: | ||||
| Charge my (check one): | Mastercard | Visa | ||
| Name on Card: | #: | Expires: / | ||
| Signature: | ||||
| Thank You! | ||||