A Division of Airline Media Productions, Inc.

1050 Oak Creek Drive, Lombard, Illinois 60148

Telephone (800) 890-9494 * (847) 470-8164 * Fax (847) 470-8194
Attention: LOIS MCDONALD

COLLEGE ORDER FORM

Name:

Title:

College Name:

Department: ______________________

Street Address:
City, State, Zip Code:
Email:

Phone:

Screening Location: _________________________________________________________________________

Address: ____________________________________________City, State, Zip: _________________________

BILLING (if different from shipping location)

Name:

Title:

Organization:

Department: ______________________

Street Address:
City, State, Zip Code:
Email:

Phone:

REQUEST
Movie Title:
Screening date (s):
Format:

Charging Admission:

(Y / N)

(35mm, Send DVD, VHS, Site License/ I will supply my own copy)

PLEASE NOTE: shipping is $50 inbound for 35mm and $20 roundtrip for DVD and VHS

Indoors / Outdoors:
Posters:

Estimated audience size:

(Y / N) Please specify amount required

PLEASE NOTE: Posters are $5 each

FORM COMPLETED BY:

DATE:
CREDIT CARD PAYMENTS

Name on Card:
Credit Card Number: _____________________________________________Exp. Date: __________________
CV2 Security Code: _____________ Would you like CRITERION to keep the card on file: __YES / ___NO