Dennis Wiskow's Auto Art Gallery
1601 Western Ave   Green Bay, WI 54303

Print and mail form to above address

Ordered by: Ship to:
Name: Name:
Address: Business Name:
City: Address:
State, Zip: City:
Day Phone: State, Zip:
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If paying by credit card, please be sure that your name and address are exactly the same as your credit card billing statement
Quantity Description Price Each Total
Merchandise Total  
Shipping & Handling (see below)  
WI Sales Tax 5.5%
(Wisconsin Residents Only!)
Method of Payment
Check _____ Bank Check _____ Money Order ____ VISA ____ MasterCard ___ DiscoverCard ___
Card Number                                

Exp. Date __ __ / __ __     CVC #(back of card) __ __ __

Signature(for credit card): _________________________________________________


United States
$8.50 for 1-3 items
$1.00 each additional item
$12.00 for 1-3 items
$1.00 each additional item
All Other Countries
$16.00 for 1-3 items
$2.00 each additional item