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.

Thank you for your order!

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.

Name: _____________________________________________________________________

Address: ___________________________________________________________________

City: ___________________________ State: ____________________ Zip: ______________

Phone: ___________________________ Fax: ___________________________

E-mail: ___________________________

1. Potentials-The Set $99.95
2. Volume 1 $29.95
3. Volume 2 $29.95
4. Volume 3 $29.95
5. Volume 4 $29.95
Tax (CA residents add 8.25%)

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

  • May purchase the set for only $195.00
  • Each individual video for only $49.95

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.

Make Check or money order (in US funds only) payable to Potentials Media

Potentials Media
PO Box 6235
San Pedro, CA 90734-6235
Fax 310-782-8488


Please allow time for check clearance. U.S. Funds only.

No returns except for exchanges on defective tapes within 30 days of purchase.
Prices are subject to change.

Your agreement with the terms and conditions listed herein is a condition of this sale.


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