Order Form

Kay Polito Studio - 3040 Chili Avenue - Rochester, New York 14624

To order, this form may be printed, filled
out and mailed to the studio.

Name:   _____________________________________________

Address:  _____________________________________________

City, State, Zipcode:  ______________________________________

Email Address:  ________________________________
(**Your email address is NEVER shared with anyone.)

Shipping Address  (only if different than above)

Name:  __________________________________________________

Address:  __________________________________________________

City, State, Zipcode:  _________________________________________

Title of Print:

____________________________________________________________

Quantity: ______ Price: _____Total amount on this line: ________

If you would like the print personalized by the artist, please write
what you would like here:_______________________________

__________________________________________________

NY State residents please add 8% Sales Tax: ______

Shipping charge: Orders under $20- free
Orders $20-$30-free
Orders$65-$125-free
(* An additional $2.00 is added for multiple items.)

Print(s)_______+ Tax (NY only): ________+ Shipping:  = ____

____________Total Amount

Please make your check or money order payable to the Kay Polito Studio.
After your check clears, any print you ordered will be mailed to you.

Thank You!

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