World Video Electronics, Inc.
4235 Sunbeam Rd. Jacksonville, Florida 32257
Phone: (904) 731-7474 Fax: (904) 733-8768

FOREIGN CONVERSION
ORDER FORM

Please complete this form, print it out, and attach with your order.

NAME:

ADDRESS:

CITY:

STATE:

ZIP:

HOME PHONE:

WORK PHONE:

E-MAIL ADDRESS:

Payment Options:

Account #

Expiration Date:

Name as it appears on my credit card for this purchase.

Signature:______________________________

Return Shipping and Handling Preference:

Please indicate conversion services requested:

From: (country/standard)
To: (country/standard)

How many total copies should we produce for you?

How did you find us?

Terms and Conditions: I authorize the above stated work to be performed. I understand that I am responsible for any royalties which may be due, for obtaining permission to duplicate any copyrighted materials, and for the total content of the finished duplication. I do not hold World Video Electronics, Inc. liable for anything that should happen to property left, due to mechanical, technical, fire, flood, or natural disaster. If paying by credit card, I authorize the charges for the costs associated with this order including shipping and handling. Note: Florida residents will be charged 7% state sales tax.

I have read the agreement and submit my order to World Video Electronics, Inc. in accordance with the preceding terms and conditions:

Authorized signature____________________________ Date________________

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