A
Mirror Image 
(240)460-9197
A
Mirror Image
To Order a copy of any portrait in our web gallery, please download and complete
this form (or print this page) and send to:
Mirror Image Photography
P.O. Box 44166
Fort Washington, MD 20744.
Please include your payment with order. We accept Major Credit Cards also. We also take orders over the phone. Just Call 240-460-9197. Each portrait can be referenced by the number on the 'Description' line.
Prices: 11x14s -
$65.00 each 8x10s -
$25.00 each 5x7s - $15.00 each 4x6s - $10.00 each
(8 wallets - $12.00)
Order Form
Personal Information
This is the address to which your receipt will be sent, and also the address to
which products will be shipped unless otherwise specified below.
Name
_______________________________________________________
Address
_______________________________________________________
City
_________________________ State ____ Zip ________________
Phone
_______________________________________________________
E-Mail Address _______________________________________________________
Shipping Information
Only complete this area if you would like the products to be
shipped to an address other than the one listed above (i.e. a gift).
Name _______________________________________________________
Address _______________________________________________________
City _________________________ State ______ Zip
________________
Credit Information (If not paying by check or money order)
Select your credit card type:
____Visa
____Master Card
____American Express
____Check Enclosed
Name as it appears on card _________________________________________________
Credit Card Number
____________________
Expiration Date (mm/yy) __________
Event Date: ___________________ Event
Name:________________________________________
Portrait Order
Portrait ID ____________ Size: __________ # Copies__________ Total $__________
Portrait ID ____________ Size: __________ # Copies__________ Total $__________
Portrait ID ____________ Size: __________ # Copies__________ Total $__________
Portrait ID ____________ Size: __________ # Copies__________ Total $__________
Portrait ID ____________ Size: __________ # Copies__________ Total $__________
Portrait ID ____________ Size: __________ # Copies__________ Total $__________
___________________________________________Order Total
_________________
Please allow 4 weeks for delivery
Thank You For Your Order!
Thanks for being visitor number . Have a nice day!!!
