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Please fill in the the form below and print it. Enclose this form with your original tape. No information is transmitted on the internet. You can write in your credit card number on the form after printing it you prefer. Click the BACK Button when done

# of COPIES	DESCRIPTION (e.g. VHS to DVD)

NAME YOUR MOVIE

	BILLING
Which credit card would you like to use?	VISA AMEX Discover MC
Credit Card #
Expiration Date

Amount $

$25.00 per conversion (add $10 for PAL<>NTSC) and $10 per additional copy

	CONTACT INFORMATION
Phone number
Email address

	BILLING ADDRESS
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Shipping address same as Billing Address?	Yes No
(Fill in if No) SHIPPING ADDRESS
Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

I have read and understand the terms and conditions.

Signed _______________________________ Date ___/___/___