From the Heart Media Inc. - Fax Order Form

Questions??? Call our offices toll free: (866) 344-5057

Please complete this form, print it out and fax it to our office.
Our toll free fax number is (866) 344-5056.
Your tape will be shipped within 48 hours after receiving your fax.

ORDERING INFORMATION

* First Name:

* Last Name:

* Street Address:
(Same as on Credit card)

* City:

State:

Country:

* Zip/Postal Code:

Mailing Address:

* City:

* State:

* Zip/Postal Code:

* Country:

If same as Street Address check here

Phone Number:

Email Address:

Fax :

Message or Comments:

Name of Show

Quanitity:

Name of Show

Quanitity:

Name of Show

Quanitity:

Cost per each 30 minute video:	$14.95
Cost per video if ordering more than one	$12.70
Shipping and Handling for 1 video	$3.50

Shipping and Handling for 2
or more videos

$6.00 Total

California residents please add 8 1/2 % tax per video.
TO ORDER BY CREDIT CARD, PLEASE CALL OUR OFFICES
(866) 344-5057

Credit Card Info:
(Visa, Mastercard, etc.)

Name on Card:

Expiration Date:

Total Amount to be charged:

or send check and order form to:

From the Heart Media Inc.
18653 Ventura Blvd. PMB#166
Tarzana, CA 91356-4419

For questions or to order over phone call our
toll free number: (866) 344-5057