VideoGram Productions

Order Form

603-362-5262

603-489-9318

Performance Date___________Time____-  Sally Gould Dance Studio

 

PLEASE PRINT CLEARLY

 

Name_________________________________________

Address_______________________________________

City/ State________________________Zip__________

Telephone #____________________________________

If a personal check is written a telephone number is required

PLEASE MAKE ALL CHECKS PAYABLE TO:        CHUCK PIAZZA

 

Check #_______________            Visa                                      Cash__________________          Master Card                         DVD: $40.00

Credit Card #___________________________  Expiration Date_____________

Signature___________________________________________
PIN #______________

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THIS YEARS PERFORMANCE WILL BE SHOT IN WIDE SCREEN FORMAT!

Receipt

Your DVD will be mailed approx 4 to 6 weeks after the performance date. The price above includes shipping and handling cost.

Orders for DVD mailed 30 days beyond Performance Date will incur an additional $10.00 surcharge. Please mail this form promptly.

Received From:______________________

A Total of $________________ for DVD          VideoGram Rep____________

Mail Payments to VideoGram Productions, Inc. 21 Eldon Way, Atkinson, NH 03811

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