Potentials Order Form
POTENTIALS: Envisioning the New Millennium
Include all applicable information on the order form. Please do not include credit card information. We will contact you for payment information. Just be sure to include your phone number with area code where and when we can reach you. We will send you confirmation of your order via e-mail.
This order form cannot be used when ordering online, but if you print it, you can mail it or fax it to us, or you can refer to it when you call us or e-mail us your order.
City: ___________________________ State: ____________________ Zip: ______________
Phone: ___________________________ Fax: ___________________________
The above prices are for individual and home use only.
Rentals: Rental of the POTENTIALS video tapes is not permitted at any time unless specifically authorized by Potentials Media in writing.
Retailers, Schools, Libraries, Businesses and others requiring public performance licenses
Charge to my_________________________ Credit Card_________________________
Credit Card #________________________________ Expiration date______/_____
Shipping: Please add $5 for the first video, & $1 for each additional video.
Shipping on the set is $8. International shipping inquire separately.
Sales Tax: California Residents add 8.25% Sales Tax.
Payment: We accept payment by money order, personal check, Visa & MasterCard.
Please allow time for check clearance. U.S. Funds only.
No returns except for exchanges on defective tapes within 30 days of purchase.
Your agreement with the terms and conditions listed herein is a condition of this sale.
Copyright (c) 1998 Potentials Media. All rights reserved.