Please fill out this form completely to place your order via email.


Date:
Name:
Street Address:
City: State: Zip:
Daytime Phone: Evening Phone:
Items to order:


Item: QTY:
Item: QTY:
Item: QTY:
Item: QTY:

Prints are shipped flat via U.P.S.
Packaging & Shipping Charges $15.00 per Print.
Pennsylvania Residents Please Add 6% Sales Tax.
For Shipping & Handling Details for Original Art, Please Call.
Make Checks Payable to:
Countryside Prints Inc.

Total Including Shipping & Handling:

Notice: This is NOT a SECURE ecommerce site, your credit card information will be sent to us via email.
If you do not feel comfortable submitting your credit card information via email, leave this area blank, and call us at 724-228-2461 with your information.

Payment Type:
Visa
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Name on Credit Card:

Credit Card Number:

Expiration Date:

For a printable order form in PDF format click here.

You will need the free Adobe Acrobat Reader, to get it click here.

After printing, you can mail this order form to:

Countryside Prints Inc.
35 West Prospect Avenue
Washington, Pennsylvania 15301

We accept Visa, Mastercard, Discover or Checks.