Circus City Festival, Inc.

CIRCUS MEDIA REQUEST FORM
Monday, September 06, 2010

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

Call with questions: (765) 472-3918

QTY TITLE PRICE   SHIPPING
2009 Show DVD $30.00 + $5.00
50 Year Celebration: Circus City Festival Band $10.00 + $5.00
Sawdust and Spangles DVD $20.00 + $5.00

  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%