JDM Enterprises- AG
51 N 3rd Street #354
Philadelphia, PA 19106

Alexis Golden Mail Order Form

Item #

Qty

DVD Title or Clothing Item Description

 

  Price

         
         
         
         
         
         
         
     

  Shipping

 
  Total  

Postage, Shipping and Handling Charges are $5.95 for the first Item and .75 cents for each additional Item

Make Check or Money Order Payable to: CASH, or leave Blank

CASH Purchases deduct an additional 10% from the Total

(Note: Cash is green money, NOT a check or money order)

______________________________________________________________________________
Note: No orders will be shipped without a signature below!!!

I, the undersigned, hereby declare under penalty of perjury as follows:

Print your name: Your age: Today's date:
 
Signature:


Please print clearly:

Address:
Address:
City: State: Zip:
Country: Telephone:
E-mail address:

Credit Card Information:  Visa, AMEX, Discover, MasterCard or JCB  (Circle One)

Card Number: ____________________________________

Expiration Date: _____________

NOTE: Your charge will appear on your statement as JDM Enterprises

I no longer accept FAX Orders