Film and Video Library Order Form

Show Date

Your Name

Mailing Address
     Town, State Zip

Shipping Address (must include name of school or business, department, street address (can't ship to P.O. boxes) and person to whose attention it should be sent. If we are shipping to your home address we need a street address, (no P.O. boxes), apartment number, etc.

     Town, State Zip

Home Phone Work Phone
Email

Date on which you will ship the video back

Will you be making the requested donation yourself or will it be made by an organization? Please specify the organization if applicable.