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A/V Order Form

Instructions
Use this form to order VHS videocassettes. Please select video titles and quantity, fill in required fields (*) and submit this form.

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

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

Play Date: *
Alternate Play Date:

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 Number:
Title:
Prefix:
First Name: *
Middle Name:
Last Name: *
Suffix:
Address 1: *
Address 2:
City: *
State: *
Zip/Postal Code: *
Country:	(Use two-letter abbreviation)
Home Phone:
Work Phone:
Fax:
E-mail Address: *