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svideo.com, Inc.

Fax Order Form.

The preferred method for ordering is via the internet. You will be taken to our secure site after you click on the check-out button.

If you have to order by fax, then you may use the form below or your own form. We accept Purchase Orders from schools and certain corporate customers only.

Order to svideo.com, Inc.

711 E. Main St.

Riverton WY 82501

http://www.svideo.com

Tel: 1 307-851-0215

Fax: 1 956-686-7450

Name: __________________________________

Bill to Address:__________________________________

City, State, Zip code: ____________________________

Your PO No.: ________________

Attention: __________________

Shipped to Address: ________________________________

________________________________

Description: _____________________________________

Product Code:

QTY:_____________



Item Cost:______

Subtotal:_______

Freight:________

Total: _______________

Name of Credit Card: ______________________________

Type of credit card: _____________________________

Credit Card No.: ___________________________________

Credit Card exp. date: _____________________________

Three digit security code: _________________________

Signature: _________________________________________