Print this form and fill out and mail to:
               Jan B.
               P.O. Box 641
               Monticello, In 47960

Please select your type: _______ (DVD) or ______ (VHS)

Name         _______________________________________________________


Address      _______________________________________________________


City/St/Zip  _______________________________________________________


Tape#        1> ______________ 2> _______________ 3> _______________


Tape#        4> ______________ 5> _______________ 6> _______________


Tape#        7> ______________ 8> _______________ 9> _______________



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*  Must DATE & SIGN and send with money the following:              * 
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*                                                                   * 
* I certify that by my signature that I am at least 21 years of age * 
*  that I wish to order photos, videos and/or materials for my own  * 
*  use in my home. I realize by law that I may not copy, publish,   *
*  resell or trade these materials said for private use. I also     *
*  realize that I am not buying any copyrights to these materials.  *
*  I further certify that I am not a city, county, state or federal * 
*  law enforcement officer, nor am I an inspector or official of US *
*  Postal Service ordering this material with the intention of using* 
*  said material as evidence for prosecution or harassment of any   * 
*  individual or organization.                                      *
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*                                                                   *
*  Signature   __________________________________ Date ___/___/___  *
*                                                                   *  
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