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Order By Phone
 1-800-716-7705
1-818-998-1890
Fax:  1-818-998-4507
Mail:  JB Video, INTERNET DEPT
         7131 Owensmouth Ave B-21
         Canoga Park, CA 91303

   Ordered by (Please Print)

Name ________________________________________

Address ______________________________________

City _____________________ State ______ Zip_______

E-mail ________________________________________

CLUB JB Username ___________________________

   Ship To (If different than Ordered By)
Name ________________________________________
Address ______________________________________
City _________________ State ________ Zip ________

ORDER CODE
TITLE
VIDEO/DVD
Total
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Shipping Info - Please Check One
()US Priority Mail: $6 first, $2 each addnt'l ()UPS 2 DAY $15 first vid, $2 each add.
()UPS 3 DAY: $14 first, $1 each add.
 ()UPS Next Day: $29 first, $3 each add.
(UPS not avail to PO Boxes)
()Canadian Air: $12 first, $3 each add.
 ()Canada FedEx: $35 first, $3 each add.
 ()Internatnl Air Mail:  $16 first, $6 add.
 ()Internatnl Fed Ex:  $40 first, $3 add.
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Subtotal

Sales Tax 8% (Cal only)

Shipping:

TOTAL

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Credit Card Information and Required Age Disclaimer
Credit Card #: ___________________________________________________CV2#_______________

Expiration Date: _____________ Signature: _______________________________________________
Form is invalid without signature: I certify that I am a resident of the city and state indicated on this form and that I am an adult under the laws of that jurisdiction regulating dissemination of sexually explicit materials to minors. I further certify that I am purchasing materials only for private viewing in my residence and that they will be safeguarded from minors. I acknowledge that any commercial exhibition of them would violate the copyright interests of J.B.Video. I am familiar with the community standards of the community where I reside and to which the materials I am ordering will be shipped, and I certify that nothing which I am ordering involves depictions which are unacceptable according to the standards of the average adult in my community.
REQUIRED SIGNATURE _____________________________________DATE_______________