Video Tape Duplication 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 _________________ Zip ________________

Phone (     )_________________________

E-Mail ________________________________

If Paying by Credit Card, Circle Credit Card Type

American Express      Discover     Mastercard      Visa

Account#____________________________ Exp. Date________ CVV Code________ Signature______________________

Length of Video___________    Quantity Ordered_________

_____ Check here for run time of video if unknown (99 cents)

__________ Check here for Proof Copy ________Express Overnite Proof Copy

    Cardboard sleeve: (  )Yes (  )No Shrink Wrap: (  )Yes (  )No

Cardboard sleeve color: (Check One)
(  )Black (  )Blue (  )Burgundy (  )Green (  )Dk Green (  )Gray (  )Gold (  )Purple (  )Red (  )Silver (  )Teal (  )White

[Keep Master on File - No Charge ( )Yes ( )No ] [Return Master - $10.00 ( )Yes ( )No] _____Separate Package

Laser printed labels , minimum 1 sheet consisting of 10 face labels or 12 spine labels

Labels must be proofed by fax for guarantee of content.

Face Label

Line #1 ____________________________________

Line #2 ____________________________________

Line #3 ____________________________________

Spine Label

Line #1 ____________________________________________

Line #2 ____________________________________________

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 obtaining permission 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.

Authorized Signature________________________________ Date_____________

Follow this link if you would like a Shipping Label for your Package   Shipping Label Link