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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
International USPS Air Mail (7-10 business days) - add  $10.00
International Fedex (3-5 business days)  - add $50.00

$


TOTAL AMOUNT


$
 

SHIPPING ADDRESS (Please Print Clearly)

NAME_____________________________________________

ADDRESS_________________________________________

CITY_____________________ ST_______ ZIP___________

PHONE NUMBER _________________________________

E-MAIL ___________________________________________

DATE OF BIRTH ___________________________________

 

PAYMENT TYPE ( CIRCLE ONE )
CHECK....MONEY ORDER....VISA....MC...AMEX...DISCOVER

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______________

<< SEND COMPLETED ORDER FORM TO A. Arias, 1301 Pleasant Ave, Griffin, GA 30223 >>