C.V.I. Fax Or Mail Order Form!
 Fill Out The Form Below,And Fax It,Or Mail To C.V.I. At:
 Custom Videomatic Inc.
5930 Keystone Drive - Bath, PA 18014
Call 1-888-347-5050 or 610-837-1478 For Orders/Inquires
or Fax us at (484)214-0046
SOLD TO:
Name: ______________________
Address:__________________________
City: _________________State:______
Zip: ___________ Phone: ___________
SHIP TO:
Name: _______________________
Address:___________________________
City: _________________State: ______
Zip: ___________ Phone: ___________
ITEM NO. QTY DESCRIPTION - PRICE EACH TOTAL PRICE
...$$
...$$
...$$
...$$
...$$
...$$
...$$
...$$
...$$
[__] Check Enclosed

$______________
Please Charge my:

[__] Discover [__] Amex [__] Visa
[__] Mastercard

Sub Total$
PA State Sales
Tax (6.00%)		$
Shipping$
Total$
I hereby authorize you to charge my credit card as payment for the above described merchandise:
Credit Card Number: __________________________________
Exp Date: ____________ Amount:____________
City: ___________________State: _______
Signature:_____________________________ Date:____/____/______/
Thank You For Your Order!