Life Portrait Service
Contact name: _______________________________________________
Delivery: ____________________________________________________
Address: _____________________________________________________
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Phone: _______________ Mobile: _________________
Email: __________________________________________
Payment by: Money Order X Direct Credit X Personal Cheque X
Please cirle: 1 x portrait $40 2 x portrait $75 3 x portrait $100
(Note: Cleared payment to commence work. Direct deposit details on request)Comments:
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Carlie Jackson Artist www.carlie.bigcity.co.nz
P.O.Box 53, Kati Kati, New Zealand Ph 021 155 6812