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
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VHS Quantity
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Play Date: *   (mm/dd/yy)
Alternate Play
Date:		   (mm/dd/yy)
Note: Please book film at least four weeks in advance of play date.
 
 
 
 
 
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: *