Prints That Heal™
Scientifically & Alternatively documented Healing Art  
                        
Order Form for Prints That Heal™
You may print out this form, fill it in and send it along with
credit or debit card information or a check or money order
payable to: Collections, Inc  or Pay Pal Email: Brent@BrentAtwater.com

                            
Please send to:
                   B Brent Atwater
                   Prints That Heal™
                   PO Box 475
                   Southern Pines, NC 28388
       
Phone: 910-692-5206 or 404-242-9022 USA
Fax: 910-692-5103

Use one form for each Print.
Thank you for your purchase!  Shipping is included in your price.

1. Print description:_____________________________________________

2. Unframed Print price: ________________________________________________

3. Quantity of this Print:___________________

Ordering Information:		Shipping Information, if different:
Name		Name
Address		Address
Address		Address
Address		Address
Phone
Email	_________________________
Name and address on Credit or Debit card:	________________________________________ ________________________________________ ________________________________________ ________________________________________
Credit or Debit card type:		Expiration date: and 3 digit Security code on back of signature strip	_______________
Credit or Debit  card number:

Pay Pal Account information:_________________________________________________

                                           _________________________________________________

If I pay by debit or credit card , I understand that by providing the following information to Ms. Atwater,
and Collections, Inc., that I agree to and I legally authorize that the debit or credit card above  be
charged to pay for Ms Atwater's artwork.  If I pay via PayPal, I agree to and authorize a transaction
to pay for Ms Atwater's artwork.

I understand and agree to the fact that every print is individualized, and that every Prints That Heal™
order must be prepaid and is non refundable.  All sales are final.

I am eighteen (18) years of age or older, of sound mind, and not under any mind altering drugs.
By signing this agreement, I acknowledge that I have read the above, have thoroughly reviewed and
understand its contents, and that I am giving my informed consent and it is my intent to agree to this
contract.  By my written acceptance of this agreement, I know this document becomes a legally
binding contract.

 Name:_____________________________________________________________________( Seal)
 Date: July 04, 2007

                                                  Insurance Shipping delivery conformation: ______________                          

                All prices at US currency rates  TOTAL AMOUNT DUE: ______________________
                                                                                                 
                                                                                 Date Paid: ______________________