ORDER FORM
(for Fax or mail)
Mail to --
JKG JadedVideo
Attention Sales
3972 Barranca Parkway J158
Irvine, CA 92606
Or Fax to --
714-596-5174
__________________________________________________ -- Name
__________________________________________________ -- Street Address
__________________________________________________ -- City
__________________________________________________ -- State
__________________________________________________ -- Zip
__________________________________________________ -- Email
__________________________________________________ -- Phone
Part Number-Media-Price-Title
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
_________ - ______ - $________ - ________________________________
$___________ -- Product Total
$___________ -- Tax (7.75%) if California
$___________ -- Shipping
$___________ -- Grand Total
Please check:
Money Order _____ OR Credit Card ______
If Credit Card please check:
American Express ____ Visa ____ Mastercard ____ Discover _____
If Credit Card: Credit --
Card# ______________________________________ Exp:______
Name: ___________________________________________
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Certificate of Compliance The graphic images contained within this website are exempt from the requirements of 18 U.S.C. S2257 of Title 18, United States Code and the regulations of 75 C.F.R. §75 because they were produced prior to July 3, 1995 or have model releases available for inspection through their respective publishers. Date of Declaration: September 1, 1998. Jaded Video reserves the right to refuse business.
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