dVD VIDEO ORDER FORM
TO BE PRINTED AND INCLUDED WITH ORDER

Order Number: ______________

Contact Information

FIRST NAME:______________ LAST NAME _______________________________

ADDRESS: __________________________________________________________

CITY/TOWN: ____________________________________ PROV.: _________

POSTAL CODE: ________________

E-MAIL ADDRESS: ______________________________________

PHONE #   __________________________________

Order Details

PACKAGE QUANTITY              PRICE TOTAL
2 HOURS VIDEOTAPE (or portion) X $39.00 = $
1 HOUR OF VIDEO (or portion) X $26.00 = $
CUSTOM PHOTO OPTION X

$5.00

 = $
ADDITIONAL SOURCE TAPES X

$5.00

 = $
DUPLICATE COPIES X

$10.00 each

 = $
SHIPPING & HANDLING   = $
TOTAL   = $ ______________
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Title Of Video: What titles do you want to be printed on the cover and on the menus? Please give a title for each video if there are more than one.
_____________________________________________________________________________________________
_____________________________________________________________________________________________

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Please provide us with as much detail as possible about your order. 

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If you are including multiple tapes be sure to label each one and explain what services are required for each. 

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If you are including multiple source tape be sure to label them so we know what order they go in.

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Please make cheque/money order payable to "Doug Johnston".

Ship To:

DVD-HOME MEDIA SERVICES
ATTN: DOUG JOHNSTON
7935 Shackleton Drive
Richmond, B.C.
V7C 5H3