Print 1st page, complete and send this form to:
SELECT MEDIA, INC.
PO Box 1084 Harriman, NY 10926
Print 1st page, complete and fax this form to:
SELECT MEDIA, INC.
Attn: Sophie
Fax: 845-774-2945
Call the Order Department at 845-774-7335 with
your order.
Call the Marketing Department
at 800-707-6334.
Ship to:
Bill to:
Attention/Title
___________________________
Attention/Title
___________________________
Organization
___________________________
Organization
___________________________
Address
___________________________
Address
___________________________
City
___________________________
City
___________________________
State ___________
Zip Code ____________
State ___________
Zip Code ____________
Telephone
___________________________
Telephone
___________________________
Fax
___________________________
Fax
___________________________
Email
___________________________
Email
___________________________
Your Order
Curricula/Video Title
Qty.
Unit Cost
Unit Total
_________________________________________________
___
$______________
$ ____________
_________________________________________________
___
$______________
$ ____________
_________________________________________________
___
$______________
$ ____________
_________________________________________________
___
$______________
$ ____________
_________________________________________________
___
$______________
$ ____________
_________________________________________________
___
$______________
$ ____________
Subtotal
$ ___________
Shipping & HandlingPlease add $12.00 for the first video or curriculum kit and $6.00 for each additional item or additional video component. (All basic curriculum packages count as 1 item. Videos for the entire curriculum packages count as separate items. i.e. S/H for one (1) Making A Difference! or Be Proud! Be Responsible! entire package is $24. S/H for one (1) Making Proud Choices! entire package is $36.)
Notes:
Prices are subject to change without notice.
The films in The AIDS Films Series are $65.00 each; any five titles is $250.00; any six titles is $300.00.
