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ORDER FORM

Customer Information
Name:
Mailing Address:
City:
Day Phone ( )
Email Address:

State:
Evening Phone (

Cell Phone (

Zip:
)

Additional Information:

PRICING for:

Vicki's Dance Recital DVD

ITEM

Qty.

2015 Recital DVD


Plus Shipping & Handling

1
2

TOTAL COST

Cost Each
$

50.00

$
$

3.00
5.00

Total
$

$
Credit Card Number:__________________________________

Please make your check payable to


Dancer's Image and mail your
Payment and Order Form to:
Dancer's Image
107 Prestwick Circle
Bossier City, LA 71111

Visa ______ - MC ________ - Discover __________ (check one)


Expiration Date:_____________________ CSV#___________________
Name on Card:_________________________________________________
Include Credit Card Billing Address if different from address above:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

We anticipate mailing DVD's within 6-8 weeks after Recital. If you have any questions, please feel free to call us at
(318) 734-5096 - Or use "Contact Us" page at: dancersimagephotography.com