Video order form

ORDER FORM FOR PRODUCTS: PRINT THIS FORM AND SEND WITH DISCLAIMER AND PAYMENT

MAIL TO: Penang Productions, 7440 Sepulveda Blvd. # 207, Van Nuys, Ca 91405 USA

ALL CHECKS/ MONEY ORDERS PAYABLE TO "PENANG PRODUCTIONS"

NAME
ADDRESS
CITY
STATE & ZIP
Phone # and email
PAYMENT BY CHECK/MONEY ORDER	CHECK # MONEY ORDER #

PRODUCTS	QUANTITY	COST	TOTAL
Item # dvd 101 (Lola's Gotta Have It !)		29.95
Item # dvd 102 ( Hose & Stockings )		29.95
Item # vhs 103 ( Black Ass Intruders )		25.00
Item # vhs 104 ( Black Hole )		25.00
Item # vhs 105 ( South Central Hookers 19)		25.00
Item # vhs 106 ( Stilettos in the Ghettos)		25.00

Shipping and Handling per item is $4.50 Each additional item add $2.50		S&H
TOTAL FOR THIS ORDER			$

Disclaimer
PLEASE SIGN YOUR NAME AND FILL IN THE DATE AFTER READING THE DISCLAIMER
AND SEND WITH YOU ORDER

LEGAL DISCLAIMER: I the undersigned herby direct LOLALANEXX.COM to mail me all brochures,dvds, videotapes,etc. I realize that these items may be considered SEXUALLY EXPLICIT. I DO NOT want the notice Sexually oriented material written on the package or envelope mailed to me. I am an adult 21 years old or older,I am purchasing these sexually oriented material for my private use in my own home. I will not show or sell them to minors. I am not ordering this material as evidence for prosecution. I have not as this date signed U.S.POSTAL FORM 2201(pursuant to 38 usc3010). I believe that this material does not offend the community standards in my ordering area .

SIGNED:______________________________________ DATE:_________________________