ORDER FORM - E3 PLAYSTATION VIDEO - IMAGE PROS
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Name     : _______________________________________________________
Address  : _______________________________________________________
           _______________________________________________________
City     : _______________________________________________________
State    : ____________________________ Zip : ____________________
Country  : _______________________________________________________
email    : _______________________________________________________

Quantity   Product                            Price      Total
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________   E3 PlayStation Video NTSC (US)*    $14.95     $________
________   E3 PlayStation Video PAL*          $19.95     $________
________   E3 PlayStation Video SECAM*        $20.95     $________
________   Shipping (Domestic US)             $ 3.00     $________
________   Shipping (Canada)                  $ 5.50     $________
________   Shipping (South America)           $ 8.50     $________
________   Shipping (Europe)                  $10.50     $________
________   Shipping (Asia, NZ, Australia)     $13.50     $________
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Sum                                                      $________
6.125% Sales Tax (US, Utah Residents ONLY!!)             $________
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Grand Total                                              $________
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* Make sure you choose the right version. 

[ ] Check (US banks only) [ ] Money Order (US currency only)
[ ] MasterCard            [ ] Visa               [ ] Discover

Card Number __________________________  Expiration Date _____ / _____
                                                        month   year

Name as it appears on Credit Card ___________________________________

To ensure quick delivery, orders must be received by May 23rd. 
Any  orders received after May 23rd will be processed, but will take 
a few days extra. Shipping will start May 27th.

Send this form to:

Image Pros
2250 N. University Pkwy. Suite #4832
Provo,  UT 84604
U.S.A.
FAX: 801-373-5999