Printable Order Form
Please make Money Orders/Checks in U.S. Dollars

SHIP TO:

 BILL TO:

Name:        _______________________

 Name:       _______________________

Co. Name: _______________________

 Co. Name: _______________________

Address:    _______________________

 Address:    _______________________
Address:    _______________________ Address:    _______________________

City:___________________ State:___________

 City:___________________  State:__________
Zip:__________ Country:_______________ Zip:__________ Country:_________________



PAYMENT METHOD:

Check#:_______   Amt. enclosed: $___________

 Phone:  (____) -______-________

Fax Number: (____) -______-________
please note there is an additional $25.00 fee for returned checks. Email Address: _____________________

Just print out this form and fill in the details and then Fax 805-530-0955 or

Mail it to: RGP Video Orders, 12490 Rainier Street, Moorpark, CA  93021.

Thank You.

Make Check payable to R G P M e d i a

Please supply the following items
PRODUCT DESCRIPTION QTY Price TOTAL AMOUNT
. . $ $
. . $ $
. . $ $
. . $ $
. . $ $
. . $ $
. . $ $
. . $ $
. . $ $
Shipping & Handling Charges:
U.S.A.=$3.50 flat rate first item, $1.00 each additional		 SUBTOTAL $
Shipping & Handling charges $

( CA State residents add 8.25% sales Tax )

 CA Add 8.25%    Tax $
Ordered by x TOTAL DUE $
Approved by x Date: .