CHRR Video Mail-In Order Form
Print Out - Fill Out - Mail In (US Funds Only)

Please send me the following 2004 Cacklefest DVD(s):

• Send me _____  Cacklefest 2004 DVD @ $24.00
• $ ____________ Total Cost of Videos Ordered - AVAILABLE NOW
• $ ____________ Shipping & Handling for each piece ordered ($4.50) -- (Canada $5.50) (Europe-UK $10.00)

Total: $________________

Please send me the following 2003 CHRR Jackson Bros. Cacklefest DVD(s):

• Send me _____  CHRR 2003 Cacklefest DVD @ $19.95
• $ ____________ Total Cost of Videos Ordered - AVAILABLE NOW
• $ ____________ Shipping & Handling for each piece ordered ($4.50) -- (Canada $5.50) (Europe-UK $10.00)

Total: $________________

Name: ___________________________________________________________

Company: ________________________________________________________

Shipping Address: __________________________________________________

City: _____________________________________________________________

State: _______________________________________ Zip Code: _____________

Mailing Address (if different): _________________________________________

Phone (Days): ____________________ Phone (Eves): _____________________

e-mail Address: ___________________________________________________

Special Instructions:________________________________________________

Select Payment Type: (include payment with form)

Check Payment Type: _____Cashiers _____ Money Order _____ Certified Check
_____ Personal Check
Check Number: __________ (personal checks need to clear our bank before order is shipped)

Make checks payable to: Left Coast Web Graphics

Mail Order Form To:
Left Coast Web Graphics
210 SW Pine St.
Grants Pass, OR  97526