LCATV PROGRAM ORDER FORM

Complete and print this form and mail it with your check made payable to LCATV to:

LCATV
354 Prim Road, Suite 3
Colchester, VT 05446

NAME OF PROGRAM:                

APPROXIMATE DATE OF PROGRAM:     CHANNEL 15 OR 16: Channel 15Channel 16               

DVD COPIES (QUANTITY): 123456789     VHS COPIES (QUANTITY): 123456789               

TOTAL NUMER OF COPIES 123456789101112131415161718 X $5.00 = TOTAL PURCHASE: $5.0010.0015.0020.0025.0030.0035.0040.0045.0050.0055.0060.0065.0070.0075.0080.0085.0090.00

NAME:                

ADDRESS 1:  
ADDRESS 2: 
CITY:
STATE:VTALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVIVAWAWVWIWY   ZIP:

PHONE:                

EMAIL ADDRESS:                

WILL YOU PICK UP OR WOULD YOU LIKE YOUR COPIES MAILED TO YOU: PICK UPMAILED               

We will call when pick-up orders are available. Mailed orders will typically arrive in 7-10 days.

Please inquire about bulk order at 862-5724 or info@lcatv.org.