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Knights of Columbus - A/V Order Form

A/V Order Form

Instructions

Use this form to order DVDs and VHS videocassettes. Please select video titles and quantity, fill in required fields (*) and submit this form. There is a $3 shipping charge for 1 to 2 DVDs or videocassettes, and a $5 shipping charge for 3 to 5 DVDs or videocassettes. For orders of more than five items, please add $1 for each additional title.

For other A/V requests, please contact the Department of Fraternal Services
at (203) 752-4270.

DVD		Quantity
1.
2.
3.
4.
5.
6.
7.
8.

VHS		Quantity
1.
2.
3.
4.
5.
6.
7.
8.

Play Date: *	(mm/dd/yy)
Alternate Play Date:	(mm/dd/yy)

Note: Please book film at least four weeks in advance of play date.

Local Council
Assembly
Circle
State Council
Agent

Council,
Assembly,
Circle
or Agent #:

Title:

Prefix:

First Name: *

Middle Name:

Last Name: *

Suffix:

Address 1: *

Address 2:

City: *

State: *

Zip/Postal
Code: *

Country:

Home Phone: *

Work Phone:

Fax:

E-mail
Address: *