Dominion Pictures - DVFilm
2317 Spring Wagon Ln
Austin TX 78728
FAX #: 512-233-2253

Please send me your DVFilm 35mm demo reel. I understand that a $300.00 deposit will be charged to my credit card, refundable if the demo reel is returned undamaged within 10 days (shipping time not included). Please charge the deposit and shipping charges (rate may vary depending on location) to my ___VISA, ___MC, ___Amex, ____ Discover, account number

__________________________________ Exp date: ______________

Note: all information on this form will be kept confidential.

Shipping (select one):

_______ Fed Ex Standard Overnight

_______ Fed Ex 2nd-day Air

_______ Fed Ex 3rd-day Express Saver

Name as it appears on card (please print):

__________________________________________

Shipping address:

___________________________________________

___________________________________________

___________________________________________

Phone number:

____________________________________________

Email address: (please print clearly so we can contact you if there is a problem or delay in your order:

_____________________________________________

Signed:_______________________________________ Date: _______________

Please mail this form to the above address or fax it to us. Please allow us 1-2 working days to process your order.