Print this page out and fax it to us.. Please print clearly.
Mr/Mrs./Ms./Miss./ My name is _______________________________________________________
My Postal Address:__________________________________ City_____________________State_____________________
Postcode____________
Telephone: Home _________________________ Business________________________
Child’s first name
Child’s Family name ______________________________
Town or Hospital of child’s birth______________________
Date of child’s birth _________________________
Day of Week of birth _________________________
Birth weight_______Time of birth_______AM ______PM ___
I wish to have TILE design number____________
at a cost of $40.00AUD plus $15.00AUD Postage in Australia
(or $28.00 AUD Postage overseas).
I wish to have the design on a PLATE size 205 mm design number_____
at a cost of $80.00AUD & $20.00AUD Postage in Australia (or $40.00) AUD postage overseas).
Or plate size 260mm $100,-AUD Postage $25,- in Australia ( or $60,- AUD postage overseas)
Personal message on the reverse side of the item:_________ ___________________________________________________________________________ ___________________________________________________________________________ Please check your information for accuracy! Alterations are not possible. If you wish to send the Birthday Tile or Plate direct to the recipient, please supply the following details: Name of recipient Mr/Mrs/Ms/Miss________________________________
Recipient’s Address:_____________________________________ City/Town_________________State____________Postcode________
Make cheques payable to: “Delft Blue Pottery” Post to: Delft Blue Pottery 235 Forest Road ( Cnr. Harcourt Road) Boronia Victoria Australia 3155. E-Mail: office@delftbluestudio.com Fax/Tel: +61 3 97621784 Card Holder Number___________/_______________/______________/____________/ Expiry Date_____________________
Mastercard_______Bank card________Visa_____A_5% surcharge will be applied for credit card payments.
Description of goods______________
Cost of goods____________________ Address_______________________
Inc. Postage. Economy/Air Aust$_____
Contact Tel:______________________ Signature______________________________________________________
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