VIDEO ORDER FORM (Print and mail with payment)

Name:____________________________________________________

Mailing Address:____________________________________________

                         :____________________________________________

City:__________________________ State:_________ ZIP:_________

Telephone:_______________________________

DVD Title 1:________________________________________________

Quantity ordered:__________  Unit price:_________  Total:____________

DVD Title 2:________________________________________________

Quantity ordered:__________  Unit price:_________  Total:____________

DVD Title 3:________________________________________________

Quantity ordered:__________  Unit price:_________  Total:____________

                                                                         Grand Total:____________  

Make check or money order payable to: The Video Factory

Mail order to:  The Video Factory;  P.O. Box 11613;  Fort Wayne, IN 46859

*Note: The Video Factory is not responsible for any damage to your video equipment while using our products.

Privacy Notice: The Video Factory does not release any of its customer information to third parties for the purpose of solicitation.

The Video Factory, 5800 Fairfield Ave., P.O. Box 11613, Fort Wayne, IN 46859

1-877-997-7722 or 260-744-6511

ANG Communications, Inc.