TALES OF A MOON GLOW

Video Order Form

The price per video VHS, or DVD is $18.95 plus tax (if ordering within CT).

How many DVD___________

How many VHS___________

add 6% sales tax (CT) _____________

add 5.00 per item for shipping and handling: _____________

Total Order: $______________

Please provide your shipping and contact information:

Name: ______________________________________________________________

Address:_____________________________________________________________

City: _____________________________________ State:________ Zip ___________

Phone: _____________________________________ Today's Date:_______________

How did you hear about the show? __________________________________________

Please print and send this form with check or money order to: (please do not send cash)

Hollywood East Entertainment

PO Box 2623

Meriden, CT 06450

Please allow 3-6 weeks for delivery. Returned check orders will be assessed a $20.00 surcharge.

For additional forms, please feel free to duplicate this form, or visit: www.talesofamoonglow.com

Thank you for your order!

If you would like a receipt for your order, please fill in and cut or tear off this portion of the form.

Paid:_________ Date: __________ Check # ___________

Hollywood East Entertainment PO Box 2623 Meriden, CT 06450 - (203) 235-4286