Mail In Video Order Form

Mail Form To: On The Edge of Cyberspace, Inc., 1509 E. Madison St. #101, Seattle WA 98122

Film ID and Title                             Check Web Site For Pricing

VHS

PAL

DVD-R

DVD+R

1

2

3

4

5

Visa

MasterCard

Merchandise (Total PRICE for all films ordered):

Discover

Money Order

State of Washington Add 8.8% Sales Tax:

Check

USA Shipping ($6 for 1 film + $1 for each extra film):

Cash

International ($10 for 1 film + $1 for each extra film):

Pay To: Edge of Cyberspace

Toll Free: 1-877-861-6951

Total Cost For This Order:

Credit Card Number:

Expire

Name on Credit Card:

Credit Card Billing Address:

City, State, Zip Code:

Telephone Number:

Shipping Name:

Shipping Street Address:

City, State, Zip Code:

Email Address:

Statement of Intent: I am an adult, aged 18 years or older. I wish to receive the adult erotic material indicated on this order form.

I am purchasing this material for my personal and private use: not for resale, not for rental and not for display to minors.

All orders must be signed. Unsigned orders will be refused.

Signed: