Print this form, fill it out clearly, sign it and send it with your order to:
Discount Duplication, 212 41st Street South Birmingham AL 35222
Phone ( )_________________________
If Paying by Credit Card Circle Credit Card Type
|American Express Discover Mastercard Visa|
|Account#_________________________________||Exp. Date________||CVV Code________||Signature______________________|
__________ # of Tapes to Convert __________Length of Video __________ # of Copies of each tape
__________ Check here for DVD-R Conversion (cost $14.99 for two hours)
______________________ Country tape or disk was made in ______________________ Country tape or disk is to be viewed in
**** Failure to complete and sign this form will delay your order.
Please read and sign. I authorize the above stated work to be performed. I understand that I am responsible for any royalties which may be due, for obtainingpermission to duplicate any copyrighted materials, and for the total content of the finished duplication. I do not hold Discount Duplication, Inc. liable for anything that should happen to property left due to mechanical, technical, fire, flood, or natural disaster. If paying by credit card, I authorize the charges for this service including shipping and handling to be charged to my card. If copyrighted tape, I have purchased and own this video for home use only. Please convert this tape for viewing on my tv.
Authorized signature__________________________________________________ Date_____________
Follow this link if you would like a Shipping Label for your Package Shipping Label Link