Payment Form – Renew Gallery Representation

Please complete the contact details below

Name(Required)

First Last

Email(Required)

Representation Option - Select the same option you have selected on the agreement

1. Representation Type

Select the representation type you have selected on the agreement

Digital

Basic

Standard

Premium

2. Digital Promotion with Representation

Select the payment option you have selected on the agreement

1 Payment Option - $2,950

3 Payment Option - $1050

6 Payment Option - $535

12 Payment Option - $275

2. Basic Representation

Select the payment option you have selected on the agreement

1 Payment Option - $5,050

3 Payment Option - $1,775

6 Payment Option - $935

2. Standard Representation

Select the payment option you have selected on the agreement

1 Payment Option - $8,075

3 Payment Option - $2,850

6 Payment Option - $1,475

2. Premium Representation

Select the payment option you have selected on the agreement

1 Payment Option - $17,595

3 Payment Option - $5,715

6 Payment Option - $2,925

Payment Method(Required)

Credit Card

Paypal

Credit Card(Required)

American Express

Discover

MasterCard

Visa

JCB

Maestro

Supported Credit Cards: American Express, Discover, MasterCard, Visa, JCB, Maestro

Card Number

Expiration Date Month Year

Security Code Cardholder Name