|
*
Please
Print Clearly * Please Print Clearly * Please Print Clearly * Please Print
Clearly * |
* Please Check Your Choice of...............
VHS Tape or
DVD
Disk * |
| First name....................................... |
_______________________________________________ |
| Last name....................................... |
_______________________________________________ |
| E-mail ( Very Important ) *......... |
_______________________________________________ |
| Shipping Address............................ |
_______________________________________________ |
| City ................................................ |
_______________________________________________ |
| State / Province............................... |
_______________________________________________ |
| Zip code.......................................... |
_______________________________________________ |
| Telephone (Ex:
555-555-5555)............... |
_______________________________________________ |
| Money Order Amount
include U.S. & Canada or International S&H $__________.00 U.S.D. |