AZERBAIJAN GALLERY
PURCHASE ORDER FORM

We must receive your purchase order form and payment to process the transaction. No return policy. No cancellation will be accepted and refunds will not be given after we have received and processed the purchase order form. Additional charges apply for shipment & handling and insurance. Please type/print clearly.

Customer Name:____________________________________________

Shipment Address: _________________________________________

City:________________________State:________Zip:______________

Country:__________________________________________________

Phone:____________________________________________________

Fax:______________________________________________________

E-mail:____________________________________________________

Merchandise Number

(Please indicate the number and price of each merchandise you would like to purchase above, calculate the total amount due and indicate the total merchandise price below).

Total Amount Due for Merchandise: $ ____________________

Shipment & Handling: $85.00 (per each item within the U.S.)

Insurance: $8.00 (per each item within the U.S.)

Total Amount Due: $ _________________ (includes total costs of the merchandise, s&h and insurance)

Form of Payment
BY CREDIT CARD (Circle One): VISA or MASTERCARD

CARDHOLDER'S NAME:_________________________________________________________

ACCOUNT #_______________________________________ EXP. DATE: _________________

TOTAL AMOUNT: ______________________ SIGNATURE: _____________________________

BY CHECK: CHECK #: __________________________________ DATE: ______________
(Please note the number of each merchandise you would like to purchase on your check)

How to Purchase:

BY FAX: PLEASE FAX THE COMPLETED PURCHASE ORDER FORM TO USACC: (202) 333-8703.
(YOU MUST INCLUDE YOUR PAYMENT INFORMATION)

BY MAIL: PLEASE MAIL THE COMPLETED PURCHASE ORDER FORM TO USACC:
1212 POTOMAC STREET, N.W. WASHINGTON, D.C. 20007
(YOU MUST INCLUDE YOUR PAYMENT INFORMATION)

USACC: 1212 Potomac Street, NW, Washington, DC 20007
Tel: 202 333 8702; Fax: 202 333 8703;
Email: chamber@usacc.org