DVD Pacific Inc.     PMB 143     10693 Wiles Road      Coral Springs     Florida, 33076

 Credit Card Type ( Check one): VISA Master Card AMEX Discover
 Card Number: _____________________________ Exp:_____/_______(Month / Year)
 Signature: __________________________________ Date: ______________________
 
 To Ship Within the US, Please check one:
   U.S.P.S.
   UPS Ground
   UPS 2nd Day Air
   DHL Priority Overnight
 See Website for posted shipping rates and delivery times.
  To Ship Outside the US, please check one: 
   Air Courier (FedEx/UPS)
   International Priority Air Mail
   International Surface Mail
   See Website for posted shipping rates and delivery times.
 BILLING ( Must be filled out )  SHIPPING ( If different from billing info)
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 First Name:    First Name:  
 Last Name:    Last Name:  
 Company:    Company:  
 E-mail Address:    E-mail Address:  
 Address line 1:    Address line 1:  
 Address line 2:    Address line 2:  
 State / Province:    State / Province:  
 Zip / Postal Code:    Zip / Postal Code:  
 Country:    Country:  
 Daytime Phone:    Daytime Phone:  
 
 ORDER INFO
Product Title  ID #  Qty.  Price  Total
       $  
       $  
       $  
       $  
       $  
       $  
       $  

 Subtotal:

  $_______________

 

 *Est. Shipping:

  $_______________

 Total:

  $_______________

Checks: Please make all money Orders or Cashiers Checks Payable to DVD Pacific.
*Actual Shipping charges will be applied based on posted rates ( http://www.dvdpacific.com/shippingInfo.asp )