PO Box 582 Anna Maria, FL 34216 941-778-2711 FAX 941-778-3341 e-mail: jack@jackelka.com www.jackelka.com

Picture Order Form See price sheet for sizes & prices. Print this form and FAX or send in you order

Name:______________________________________________________________________

Address:____________________________________________________________________

City, State, Zip:_______________________________________________________________

Phone:______________________________________________________________________

Credit Card # Master Card or Visa only_____________________________________Exp. Date______________

Check #____________________________________________________________________ Make Check Payable to Jack Elka

Picture #	Size	Quantity	Mounting	Price *

Call for pricing on special retouching
Florida residents add 6.5% State Tax. Add 6% of total for shipping & Handling over $50.00
Under $50.00 add $3.00 to cover shipping & handling