Entertainment - Video Order

Request and Order Form

When you have selected the service or entertainment you need, please fill in all REQUIRED fields marked with an asterisk (*) to avoid delays!

If you have questions regarding your order, please E-mail us. or call 1-800-410-8433.

Type of service
Entertainment Act
Video or Convention Service
*First Name:	Contact Person
*Last Name:
*E-mail:	(Please check spelling!)
Company:
*BILLING Street Address:	(As appears on your credit card statements!)
*City:
*State/Province:
*Postal Code:	(As appears on your credit card statements!)
*Country:
*Telephone:
FAX:
*Web Site

Payment Information (Order is secure on this SSL encrypted server)

(For Check/Money Orders, fill out form and submit it. Then print this form and attach with your payment when you mail check. Make checks payable to Concepts West Agency. We'll e-mail you an invoice after submitting.)

*Payment Type:
*Credit Card Number:	(Double check your entry!)
*Expires: (Month / Year)	/ (MM/YYYY)
*Name as it appears on the card:	(*Required unless sending check)
Your Reference No.: (If any)
*How did you hear about us?
Other Souce:

CAUTION: Please make sure the address entered above matches the billing address on your credit card statement exactly or order will be rejected.

Make sure phone number is correct since we may CALL for verification. You will be e-mailed a confirmation number for your request for your service(s) and a receipt as soon as your payment has been processed and verified.

For fastest service please use a credit card for deposits. Mail or overnight checks/money orders to: Concept West Agency, 1040 Matley Lane, #8, Reno, NV 89502, USA. Call 1-800-410-8433 or Email us if you have questions. You may fax the form to:
702-324-2662 if you like. However, for fastest service , please submit electronically on this SECURE server. Thank you.

Write to us at:
cwareno@aol.com

Design and Code (C )Concepts West Agency 1998
All identia (C) 1998 Concepts West Agency