| Name |
_________________________________________________________ |
|
|
| Address |
_________________________________________________________ |
|
|
| City |
_________________________________________________________ |
|
|
| State |
_________________________________________________________ |
|
|
| Zip Code |
__________________ |
|
|
| Phone Number |
_________________________________________________________ |
|
|
| How Many Tapes |
1 2
3 4 5
6 7 8
9 10 11
12 13 15
16 |
|
|
| Format |
PAL
SeCAM
NTSC |
|
|
| Convert To |
PAL
SeCAM
NTSC |
|
|
| Length |
1 HR
2 HR 3 HR 4 HR 5
HR 6 HR 7 HR 8 HR |
|
|
| Payment Method |
Visa
Master Card Discover American
Express Diners Club
| Card Number |
_____________________________ |
| Exp. Date |
______-_______ |
|
|
Billing Information:
| * Cardholders Name |
_________________________ |
| *Address |
_________________________ |
| *City |
_________________________ |
| *State |
_________________________ |
| *Zip Code |
_________________________ |
| *Country |
_________________________ |
*All fields required!
If you don't want to pay
by credit card:
|
|
I ___________________________________
authorize MiniMax Electronics, Inc. To charge my credit card, or
redeem the check (check #__________) specified above, for the
total amount for tape conversion service requested on _____________ 1999.
Sign
Here X ______________________________
|
|
|