OFFLINE ORDER FORM


	OFFLINE ORDER FORM This form may be printed in order to mail or fax it.

If you are experiencing problems with this form, please contact us

If you are experiencing problems with this form, please contact us

If you are experiencing problems with this form, please contact us

If you are experiencing problems with this form, please contact us

If you are experiencing problems with this form, please contact us

If you are experiencing problems with this form, please contact us

If you are experiencing problems with this form, please contact us

If you are experiencing problems with this form, please contact us

ITEM #	ITEM NAME	QUANTITY	COST
CTLUD	DVD of Crossing the Line For College/University at $139		0.00
CTLUV	VHS Videotape of Crossing the Line For College/University at $139		0.00
CTLND	DVD of Crossing the Line For Labor Org, NGO, Public Library or High School at $74		0.00
CTLNV	VHS Videotape of Crossing the Line For Labor Org, NGO, Public Library or High School at $74		0.00
	DHL Ground Shipping (2-3 weeks)	See table of costs
			0.00
	10% discount on 2 or more copies		0.00
	Total		0.00

PAYMENT OPTION
Your payment information will not be transmitted

Authorized Purchase Order

Institution
Purchase Order #

Payment by Check

Use only for orders via regular mail (no FAX).
Please enclose a check payable to Example.com.

Name (First/MI/Last)
Check number

Credit Card

Card Type
Card Holder Name (First/MI/Last)
Card Number (no spaces)
Card Verification Number	MC & Visa: 3 digits after number on back of card Am. Express: 4 digits on front of card above and to right of account number
Expiration Date	Month (MM) Year (YY)

SHIPPING ADDRESS

Ship to Name
Email Address
Institution
Department
Address
(no PO boxes please)
City
State
Zip/Postal Code
Country	USA (for Canada or Mexico email us)
Telephone

BILLING ADDRESS	Check if same as shipping address

Bill to Name
Email Address
Institution
Department
Address

City
State
Zip/Postal Code
Country	USA (for Canada or Mexico email us)
Telephone

PLEASE CHECK TO SEE THAT ALL FIELDS HAVE BEEN FILLED IN
before you finalize your order.

Missing information will cause delays
while we contact you.

Use your browser menu to print this form and mail
or FAX it to us.

FAX your order to: 845-774-2945

Mail your order to:
Las Lineas Media Library
Transit Media
P.O. Box 1084
Harriman, NY 10926

For questions call: 800-343-5540
or email info@transitmedia.net