Horror Theater video order form

HORROR THEATER VIDEO ORDER FORM

Please provide the following personal information:

First Name

Last Name

Date of Birth
* IF PURCHASING FILMS NOTED FOR EXTREME VIOLENCE!!!

Please provide the following ordering information:

QTY
VIDEO/DVD-R TITLE
PRICE

SUB TOTAL

REGULAR SHIPPING ($4.00 1st item $.50 for each additional item)

PRIORITY ($5.25 1st item $.75 for each additional item)

TOTAL

SHIPPING ADDRESS
Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

HORROR THEATER VIDEO
275 PLEASANT STREET
CLAREMONT, NH 03743
(603)504-6371

PAYMENT METHODS

ON-LINE: MASTERCARD/VISA. AMERICAN EXPRESS AND PAYPAL MAIL: SEND CHECK OR MONEY ORDER TO:

TO ORDER WITH YOUR CREDIT/DEBIT CARD BY TELEPHONE, CALL US AT (603) 504-6371 BETWEEN THE HOURS OF 9:00am TO 5:00pm EASTERN TIME 7 DAYS A WEEK.

First Name
Last Name
Date of Birth	* IF PURCHASING FILMS NOTED FOR EXTREME VIOLENCE!!!

QTY	VIDEO/DVD-R TITLE	PRICE










	SUB TOTAL
	REGULAR SHIPPING ($4.00 1st item $.50 for each additional item)
	PRIORITY ($5.25 1st item $.75 for each additional item)
	TOTAL

	SHIPPING ADDRESS
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country