Sold To: Name:  
  Street Address:  
  City, State, Zip:  
  Telephone:  
     
Ship To: Name:  
  Street Address:  
  City, State, Zip  
  Telephone:  
     
Please Check Payment Method:            
    Check   Money Order   C.O.D.  
    (US Mail)   (US Mail)   (FAX)  
             
Style#   Description Unit Cost Qty Subtotal
1          
2          
3          
4          
5          
6          
7                  
8                  
9                  
10                  
16          
17          
    Subtotal  
Please Fax C.O.D. Orders To:   CA Resident add 8.25% Tax  
Fax:  (734) 939-4260   Add $30 per Panel S & H  
    Total  
Please Send Payment To:      
West Coast Gallery    
4113 Nipomo Avenue    
Lakewood, CA 90713