Please print out & complete this form and send/fax it to:

Video By Design,
Croesnewydd Hall, Wrexham Technology Park,
Wrexham, LL13 7YP, UK.

UK Orders:Telephone (01978) 366060. Fax (01978) 290705
Outside UK: (44) 1978 366060. Fax (44) 1978 290705

Name: ________________________________________________________________________

Address: ______________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Postcode: _____________________________________Country:__________________________

Phone: ________________________Email:___________________________________________

Video Details:
Video Format (If known, otherwise we can go by your country.)____________________________

Video Ref.No.____________Title__________________________________ Price - £_________

Video Ref.No.____________Title__________________________________ Price - £_________

Video Ref.No.____________Title__________________________________ Price - £_________

Video Ref.No.____________Title__________________________________ Price - £_________

Video Ref.No.____________Title__________________________________ Price - £_________

Video Ref.No.____________Title__________________________________ Price - £_________

Postage & Packing - (UK) £1.00 per video - (International)£3.00 per video...... Total: £ ________

___________________________________________________GRAND TOTAL - £_________

I have enclosed a Cheque for: £ ________________________ Made payable to Video By Design

or please debit my *Visa / Mastercard (* please circle)

Card No.: _______________________________________Expiry Date ____________________

Name on Card_______________________Signature of Cardholder_________________________

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