Circus City Festival, Inc.

CIRCUS MEDIA REQUEST FORM
Friday, May 09, 2008

Make checks payable to:
Circus City Festival, Inc.
154 N. Broadway
Peru, IN 46970

Call with questions: (765) 472-3918

QTY TITLE PRICE   SHIPPING
2005 DVD $30.00 + $4.00
2005Video Tape $23.00 + $4.00
2006 DVD $30.00 + $4.00
2006 Video Tape $23.00 + $4.00
2007 DVD $30.00 + $4.00
2007 Video Tape $23.00 + $4.00
The Best of The Peru Circus Festival Band CD $15.00 + $4.00

  AMOUNT ENCLOSED $ 
NAME:
ADDRESS:
CITY:
STATE:
ZIPCODE:
PHONE:
EMAIL:
 
WHERE/HOW DID YOU HEAR ABOUT US? RADIO TV NEWSPAPER WEBSITE OTHER
 
VISA/MC ONLY
CARD #
EXP. DATE:
NAME IMPRINTED ON CARD:
  Cancellation Fee of 10%