ORDER FORM

"Fish and Wildlife"

FRAMED PRICE INCLUDES PRINT PRICE

Qty

____ Print only $60.00 --------------------------- $ ___________

____ Framed Print $135.00 -------------------- $ ___________

Sub-Total ------------- $ ___________

6% KY Sales Tax --------- $ ___________

Shipping & Insurance --------- $ ___________

(Print(s) - $7.50/framed print - $12.50)

GRAND TOTAL -------- $ ___________

Please provide following information:

Name & Rank of Officer _______________________________

(first name and middle initial)

Unit Number ________       Serving Since Date _________

Frame preference:

__ Black       __ Cherry      __ Oak       __   Pecan

To Place an order call 606-633-8757 or complete order form and
mail with check, money order or credit card information to:

OMNI Gallery
102 Whitesburg Plaza
Whitesburg, Kentucky   41858

Please provide contact & shipping information:

Name: ___________________________________________

Address __________________________________________

_________________________________________________

_________________________________________________

Daytime Phone: _________________________

(circle one)  visa / mastercard / american express / discover

Credit Card # _____________________________________

exp date __________

Name on Card  ____________________________________