| Ordered Video Numbers |
#___/ #___/ #___/ #___/ #___/
#___/ #___/ #___/ #___ |
| Name & Date |
____________________________
____/____/____ |
| Phone |
area code ( _____ )
____________________________ |
| Address |
____________________________________________ |
| City |
____________________________________________ |
| State & Zip Code |
____________________________________________ |
| Payment Type |
Check _ Money Order _ Visa _ M/C _ AmEx _ |
| Visa-M/C-AmEx # |
__ __ __ __ __ __ __ __ __ __ __
__ __ __ __ __ |
| Expiration Date |
______ / ______
Signature ___________________ |
| Total Enclosed |
First Tape
....................................................
$6.95
_____ Additional Tapes ($6.95 each)..........$ _______
Sub-total
......................................................$
_______
Shipping & Handling total fee (see above)..... $ _______
TOTAL
.......................................................
$ _______
|