Information about http://www.shootonline.com/go/images/newdirectorsccform.pdf
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Tags: accounting department, address fax, address phone, american express, billing address, billing mailing address, business media, card number exp, card security, country zip code, discover credit card, fax email, mailing address street, mastercard visa american express, phone billing, security code, shipping charges, state province, visa american express, westport ct,Pages: 1
Language: english
Created: Tue May 30 11:32:18 2006
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Creditt iCard
Authoriza onForm
PLEASE COMPLETE THE INFORMATION BELOW AND FAX BACK TO: 203.227.2787
Yes, please rush me The 2008 SHOOT New Directors Showcase DVD. I authorize DCA
Business Media LLC (dba SHOOT) to charge:
$29.95 (U.S.) To cover DVD Duping, handling & shipping charges.
Name On Card*: _______________________________*Security Code___________
Credit Card Type*: ___ MasterCard ___ Visa ___ American Express ___ Discover
Credit Card Number*: ________________________________ Exp. Date*:________
Cardholder's Contact Information, including billing/mailing address:
Street Address*: _______________________________________________________
Suite/Apt. No.*: _______________________________________________________
City*:________________________________________________________________
State/Province/District*: _________________________________________________
Country*: _____________________________ Zip Code*:_____________________
Contact Phone*: _______________ Billing Address Phone: _________________
Billing Address Fax: ____________________
Email Address: _____________________@_________________________________
Signature*:________________________ Business Name:*_____________________
Printed Name*: _____________________________ Date*:____________________
* Denotes required information to process.
SHOOT, Accounting Department, 21 Charles Street, #203, Westport, CT 06880 FOR SERVICE INQUIRES PLEASE CALL: 1.203.227.1699 x12