aloha-dvd.com MAIL & FAX ORDER　 Ordred DATE:

Please print out this form & FAX to 808-943-1552　or mail to 1518-G Makaloa St Honolulu, Hi 96814

Your name
Billing address
Phone #
E-Mail
FAX #

shipping address

Name
shipping address
Phone #

The exact name of the products or titles you wish to purchase. Remember that different studios often release movies with identical titles, so it is useful to include the studio's name or names of stars in the movie.	ITEM #	price
TOTAL:

Payment *Sorry! We do not accept personal checks

□credit card	Name on the credit card:
*Security Code - 3 or 4 digit number which is not part of your credit card number. It appears only on your credit card. VISA/MASTER have the code in the last 3 digits of the number printed on the back of the card in the signature field. AMEX - printed on the front	VISA MASTER JCB AMEX
	Credit card number:
	Expiration date (mm/yy)：　　　 　/
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	Card Holder Signature ; I declare under penalty of perjury that I am at least 21 years of age