RudeBoy Video |
FAX THIS COMPLETED FORM TO: 1-480-452-0115
OR
SEND BY MAIL TO:  Please be sure to include a valid email address or fax# below if you want us to email or fax you an order confirmation. MONEY ORDERS MUST BE DRAWN IN US DOLLARS |
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PAYMENT METHOD |
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The charge will appear on
your credit card statement from "RudeBox Media, Inc."
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CREDIT
CARD # |
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| CREDIT CARD BILLING NAME & ADDRESS (REQUIRED FOR CREDIT CARD ORDERS) | |
NAME |
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ADDRESS |
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CITY / STATE / ZIP CODE |
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| EMAIL ADDRESS (optional) | |
FAX NUMBER
(optional) |
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| SHIPPING ADDRESS (IF DIFFERENT FROM BILLING ADDRESS) | |
NAME |
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ADDRESS |
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CITY / STATE / ZIP CODE |
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WE
MUST HAVE YOUR SIGNATURE TO FILL YOUR ORDER |
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| By signing below,
I hereby certify that I am at least 18 years of age and am ordering
adult oriented material for my personal, private use. Further, I
declare that the material I am ordering is not unlawful to possess in
my community, nor is it unlawful to ship these materials into my
jurisdiction via interstate transport. I indemnify RudeBox Media, Inc. from any damages resulting from the misuse of these products.
I hereby authorize this charge to my credit card. Signature: ____________________________________________ |
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PLEASE
SEND ME THE FOLLOWING ITEMS |
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ITEM
# |
VIDEO
TITLE |
QTY |
PRICE |
ORDER SUB TOTAL |
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US PRIORITY MAIL SHIPPING CHARGES |
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USA |
$5.50 flat rate Free if order is $100 or more before tax/shipping |
CANADA |
$10.00
for first item plus $1.00 for each additional item |
OVERNIGHT USA ONLY |
$25
for first item plus $2.50 for each additional item |
NO
FOREIGN CHECKS ACCEPTED CASH IS SENT AT BUYER'S RISK |
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ORDER SUB TOTAL |
$ |
+
7.95% SALES TAX (Arizona only) |
$ |
+ SHIPPING (see above) |
$ |
= ORDER TOTAL |
$ |