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BWN VIDEO ORDER FORM
| NAME OF DVD | ITEM PRICE |
| $ | |
| $ | |
| $ | |
| $ | |
| $ | |
TOTAL FOR THIS ORDER |
$ |
Georgia Residents add 7% Tax |
$ |
Enter Desired Shipping Method Charge (required) U.S. Priority Mail (3-4 business days) - add $5.00 |
$ |
|
$ |
SHIPPING ADDRESS (Please Print Clearly) NAME_____________________________________________ ADDRESS_________________________________________ CITY_____________________ ST_______ ZIP___________ PHONE NUMBER _________________________________ E-MAIL ___________________________________________ DATE OF BIRTH ___________________________________ |
PAYMENT TYPE ( CIRCLE ONE ) NAME ON CARD __________________________________ CARD# ___________________________________ EXP. DATE ______________ CVV# (3/4 DIGIT CODE ON BACK OF CARD)____________ SIGNATURE ________________________________________ |
I DECLARE: By signing this form, I declare under penalty of perjury that I am over 21 years of age. I knowingly desire receiving sexually oriented material for my own use and permit you to mail me such material. I will never show such material to minors, and I believe that such material does not offend the standards of my community. I have not requested the Post Office or anyone else to protect me against receipt of such material. I am not a Postal Inspector, a Law Enforcement Official or act as an agent thereof, attempting to obtain evidence for the purpose of entrapment. I order these videos for personal use and exercise my First Amendment rights by viewing videos and DVDs in the privacy of my own home for recreational and educational purposes. All of the above is understood and the following is true. (WE WILL NOT SHIP WITHOUT SIGNATURE.)
Signature_____________________________________ Date______________
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