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Print this form, fill it out clearly, sign it and send it with your order to: Discount Duplication, 240 Oxmoor Circle, Suite 102, Birmingham, AL 35209 |
Name
______________________________________
Address ______________________________________ City ______________________________________ State _________________ |
Phone ( )_________________________ E-Mail ________________________________ Zip ________________ |
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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_____________
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