Check  Money Order Total Amount Enclosed: $__________ |
| Credit Card #:______________________ Visa MC AE |
| Bank Name on Card:_________________________ Exp._______ |
| Customer #:___________________________________________ |
| Name:_______________________________________________ |
| Street Address:________________________________________ |
| City:__________________________ State:_____ Zip:_________ |
| Country:__________________ E:Mail #: ____________________ |
| Phone #:_______________________ Fax #:_________________ |
| Format: = -VHS (NTSC) -DVD |
| Please list TITLES, STOCK NUMBERS and PRICES below: |
| 1.)_____________________________ #__________ $________ |
| 2.)_____________________________ #__________ $________ |
| 3.)_____________________________ #__________ $________ |
| 4.)_____________________________ #__________ $________ |
| 5.)_____________________________ #__________ $________ |
| 6.)_____________________________ #__________ $________ |
| 7.)_____________________________ #__________ $________ |
| 8.)_____________________________ #__________ $________ |
| 9.)_____________________________ #__________ $________ |
| 10.)_____________________________ #__________ $________ |
| 11.)_____________________________ #__________ $________ |
| 12.)_____________________________ #__________ $________ |
| 13.)_____________________________ #__________ $________ |
| 14.)_____________________________ #__________ $________ |
| 15.)_____________________________ #__________ $________ |
