2006 South 57th Street, Temple, TX 76504

RECORDING MEMBER INFORMATION

First Name:

Last Name:

Mailing Address:

City:

State:

Zip:

Phone:

email:

VIDEO REQUEST FORM

All prices are suggested donations for cost recovery of producton and services.

Suggested

Enclosed

Video Title Name

DVD #

$5.00

$

Video Title Name

DVD #

$5.00

$

Video Title Name

DVD #

$5.00

$

Video Title Name

DVD #

$5.00

$

Video Title Name

DVD #

$5.00

$

Video Title Name

DVD #

$5.00

$

Video Title Name

DVD #

$5.00

$

FOR OFFICE USE

Date Received:

Sub Total

$

Start Mailing Date:

Shipping

$

5.00

Renewal Date:

Love Offering

$

Total Enclosed

$

Make personal checks or money orders out to Agudat Bris.  Please do not send cash.

Mail to:

Agudat Bris / Covenant Fellowship

ATTN: Video Productions

2006 South 57th Street

Temple, TX 76504