BILLING INFORMATION:

Credit Card Type:______________________ Exp Date_________________________
Credit Card Number:____________________________________________________
Name on Credit Card____________________________________________________
Signature of Card Holder_________________________________________________
Federal I.D. or Taxpayers number__________________________________________

SHIPPING ADDRESS

Name:_________________________________________________________________
Address:_______________________________________________________________
City____________________________ State___________________ Zip____________
Phone______________________________ Fax:_______________________________
Email_________________________________________________________________

TAPE/TITLE #
_______________ $__________________
_______________ $__________________
_______________ $__________________
_______________ $__________________

BOOKS/TAPE# _______________ __________________
_______________ __________________
_______________ __________________
_______________ __________________
GRAND TOTAL __________________

Note: Sales tax, shipping and handling plus a $5.00 fee will be added to all orders

FAX ORDERS TO (619) 296-4532 OR EMAIL TO info@jcntv.com