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.



* First Name:
* Last Name:
* Street Address:
(Same as on Credit card)
* City:
* 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:

Yearners and Protectors:
Which One Are You?

To order by credit card, please call our office first @
(866) 344-5057

Cost per video: $29.95
Free Video (14.95 Value)  
Shipping and Handling $5.00
California residents please add 8 1/4% tax per video. = $2.47
(Total per video set with sales tax = $37.42)
Credit Card Info:
(Visa, Mastercard, etc.)
Name on Card:
Expiration Date:
Total Amount to be charged:
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