PURCHASE REQUEST FORM

• By filling out and sending the Purchase Request Form below you agree to:
  
  
• Pay for the painting requested as indicated by the Painting Number on the www.galerialapoza.com website
  
  
• Pay for the painting requested in U.S. Dollars as indicated on the www.galerialapoza.com website. NOTE: All the works shown in the La Poza "galeria" are in private collections and museums. The only pieces for sale are shown under "new work".
  
  
• Make payment to the bank account specified by the seller, Libusche Wiesendanger, in the follow-up email or fax
  
  
• The cost for the insured shipment of the painting by dhl will be split between the seller and the buyer.
  
  
• Accept this Purchase Request Form as legally binding
  

Upon receiving the Purchase Request Form below we agree to:

• Send you a confirmation of your purchase by email or fax
  
  
• Send you payment instructions for your purchase by email or fax
  

Thank you for your interest.

-- Libusche Wiesendanger

Please fill out all fields that are underlined.

Name:
Address One:
Address Two:
City/Town:
State/Province:
Postal Code:
Country:
Email:
Telephone with Area Code;
Painting Number;
Painting Price;
Do you have any questions or comments?