video conversion order form

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

   Name ______________________________________

Address ______________________________________

   City ______________________________________

  State _________________


Phone (      )_________________________

 E-Mail ________________________________ 

Zip ________________

If Paying by Credit Card Circle Credit Card Type

American Express Discover Mastercard Visa

Account#_________________________________ Exp. Date________ CVV Code________ Signature______________________

$14.99 for up to 2 hours of DVD or VHS conversion

__________ # 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