TO ORDER BY MAIL: Print this form, complete it and mail it to:
3rd World Video, 151 First Ave., #187, New York, NY 10003

WE DO NOT ACCEPT ORDERS FROM THE FOLLOWING AREAS:
ALABAMA - zip codes beginning with 366 
FLORIDA - zip codes beginning with 323 and 325
KENTUCKY - Prohibited    
MINNESOTA - zip codes beginning with 557 and 558
MISSISSIPPI - Prohibited
MONTANA - zip codes beginning with 591  
NEBRASKA - zip codes beginning with 681 and 685
NEW YORK -zip codes beginning with 103
NORTH CAROLINA - zip codes beginning with 282
OHIO - zip codes beginning with 452  
OKLAHOMA - Prohibited
SOUTH CAROLINA - Prohibited
TENNESSEE - Prohibited    
UTAH - Prohibited     
VIRGINIA -zip codes beginning with 223

Name (Print)______________________________________
Street (NO P.O.BOX)___________________________________________
City _______________________ State _______ Zip Code _________
Country__________________________
Phone Number: _________________________
Email Address: _________________________________  
[   ] Please add me to your special Internet mailing list .

     You must sign the statement below. .
I AFFIRM that I am at least 21 years of age and wish to receive sexually explicit
material from 3rd World Video for my own personal and private use only.
I am not affiliated with any law enforcement agency, censorship group, or the
US Postal Service, nor am I aiding them in any way. The merchandise shipped
to the address above does not violate the laws to which it is a part.

SIGNATURE: ____________________________________
                   TITLE                                      CODE                 PRICE
1 - __________________________         ________       $___________
2 - __________________________         ________         ___________
3 - __________________________         ________         ___________
4 - __________________________         ________         ___________ 
5 - __________________________         ________         ___________
6 - __________________________         ________         ___________

MERCHANDISE TOTAL:  $_____________
NY Residents add 8.5% Sales Tax:  $_________
U.S.UPS Shipping:
$7.50 1st DVD, $1.50 each addtl. DVD $_________
AK, HI & other 2nd Day Air, add additional $7.00 $___________
Outside the U.S. via post, $20.00 $_______________

TOTAL PURCHASE: $___________

Check one: CHECK___ MONEY ORDER____
CREDIT CARD: VISA___ M/C___ AMEX___DISCOVER___

CARD #:____________________________________EXP.DATE_____
CVV2#_________ (3 digit # on back of card)

ALL PURCHASES ARE FINAL.
In case of defect, we will replace the SAME TITLE ONLY.
Shipping & Handling:Orders are usually shipped within 24 hours of receipt. All orders are sent UPS only.
Alaska and Hawaii are automatically shipped 2nd Day Air. We must have a street address
as UPS does not deliver to post office boxes. 2nd Day Air does not guarantee sooner
shipment, only faster delivery! Please allow 1 to 3 weeks for delivery.
MAIL TO: 3rd World Video, 151 First Ave., #187, New York, NY 10003