Check  Money Order Cash (US Dollars) M4M Credit |
| Credit Card #:____________________ Visa MC DC |
| Bank Name on Card:_________________________ Exp._______ |
| Customer #:___________________________________________ |
| Name:_______________________________________________ |
| Street Address:________________________________________ |
| City:__________________________ State:_____ Zip:_________ |
| Country:__________________ Email: ____________________ |
| Phone #:_______________________ Fax #:_________________ |
| Format: = DVD Blu-Ray Adult Sex Toys |
HOLD UNTIL COMPLETE: To wait until the entire order is complete before shipping (to minimize shipping costs).
SHIP AS SOON AS POSSIBLE: To ship the movies as they become available (extra shipping costs will apply) |
| Please list TITLES, STOCK NUMBERS and PRICES below: |
| 1.)_____________________________ #__________ $________ |
| 2.)_____________________________ #__________ $________ |
| 3.)_____________________________ #__________ $________ |
| 4.)_____________________________ #__________ $________ |
| 5.)_____________________________ #__________ $________ |
| 6.)_____________________________ #__________ $________ |
| 7.)_____________________________ #__________ $________ |
| 8.)_____________________________ #__________ $________ |
| 9.)_____________________________ #__________ $________ |
| 10.)_____________________________ #__________ $________ |
| 11.)_____________________________ #__________ $________ |
| 12.)_____________________________ #__________ $________ |
| 13.)_____________________________ #__________ $________ |
| 14.)_____________________________ #__________ $________ |
| 15.)_____________________________ #__________ $________ |
| Total Amount Enclosed: $__________ |
AGE VERIFICATION
___________________________________________________
I certify by my signature that I am an adult, 18 years of age or older, and that I wish to receive this merchandise for my personal use. |
