GLIMPSE VIDEO ORDER FORM (revised 04/14/11) Please circle format wanted: NTSC PAL (NOTE: NTSC is the format used in North American and Japan and PAL is used in most other countries.) Glimpse DVDs are $40.00 each. Please check each item that applies: DVD ___ Pissgirl the movie ................................ $___________ ___ Some Like it Wet .................................. $___________ ___ Slippery When Wet ................................. $___________ ___ Piss 'n' Mix ...................................... $___________ ___ Piss 'n' Mix 2 .................................... $___________ ___ Piss 'n' Mix 3 .................................... $___________ ___ Wet Weekend ....................................... $___________ ___ Piss 'n' Mix 4 .................................... $___________ ___ Piss 'n' Mix 5 .................................... $___________ ___ Piss 'n' Mix 6 .................................... $___________ ___ Piss 'n' Mix 7 .................................... $___________ ___ Piss 'n' Mix 8 .................................... $___________ ___ Piss 'n' Mix 9 .................................... $___________ ___ Piss 'n' Mix 10 ................................... $___________ ___ Piss Flix 1 ....................................... $___________ ___ Piss Flix 2 ....................................... $___________ ___ Piss Flix 3 ....................................... $___________ ___ Piss Flix 4 ....................................... $___________ ___ Piss Flix 5 ....................................... $___________ ___ Super Soaker ...................................... $___________ ___ Deeper Wetter ..................................... $___________ ___ Slash Dot Com ..................................... $___________ ___ Splash Vol. 1 ..................................... $___________ ___ Splash Vol. 2 ..................................... $___________ ___ DepthCharge Vol. 1 ................................ $___________ ___ DepthCharge Vol. 2 ................................ $___________ ___ Bump (80 minutes) ................................. $___________ ___ Wipeout 1 (90 minutes) ............................ $___________ ___ Wipeout 2 (90 minutes) ............................ $___________ ___ Piss Artist (90 minutes) .......................... $___________ ___ One Night in Badcock 1 (67 minutes) ............... $___________ ___ One Night in Badcock 2 (66 minutes) ............... $___________ ___ One Night in Badcock 3 (66 minutes) ............... $___________ ___ On the Piss 1 (70 minutes) ........................ $___________ ___ On the Piss 2 (66 minutes) ........................ $___________ ___ On the Piss 3 (70 minutes) ........................ $___________ ___ Pandora's Box 1 (90 minutes) ...................... $___________ ___ Pandora's Box 2 (90 minutes) ...................... $___________ ___ Pandora's Box 3 (90 minutes) ...................... $___________ ___ Pandora's Box 4 (90 minutes) ...................... $___________ ___ Streak of Piss 1 (90 minutes) ..................... $___________ ___ Streak of Piss 2 (90 minutes) ..................... $___________ ___ Pissario 1 (90 minutes) ........................... $___________ ___ Pissario 2 (85 minutes) ........................... $___________ ___ Pissario 3 (95 minutes) ........................... $___________ Pee Garden DVD's are $50.00 each. DVD ___ Pee Garden 1 ...................................... $___________ ___ Pee Garden 2 ...................................... $___________ ___ Pee Garden 3 ...................................... $___________ ___ Pee Garden 4 ...................................... $___________ ___ Pee Garden 5 ...................................... $___________ ___ URBAN - Mediterranean Girls ....................... $___________ Subtotal .............................................. $___________ Credit Card orders - add $2.00 per title service charge on titles that are $40.00 and a $3.00 per title service charge on titles that are $50.00 ...................... $___________ Australian orders paid by credit card will have a 10% GST tax added to their total .................... $___________ Overnight delivery by Express Mail (US Only) add $25.00 for 1 to 4 videos, add $30.00 for 5 to 7 videos, add $35.00 for 8 to 10 videos ............................. $___________ Glimpse and Pee Garden DVDs are shipped by Patches' Place and Wet Set. Prices include shipping anywhere. Total $___________ ___I DO NOT want to require a signature to receive my order. ___Do NOT send me information about new products. ___Send future info by ___ e-mail or ___ to my mailing address. PAYMENT METHOD: ___Check ___Money Order (payable to Patches' Place) ___ Cash ___Visa ___MasterCard ___ Bankcard Card #_________________________________________ Expires ___________ Security Code ________ (last 3 digits on the back of the Credit Card above your signature) Credit card payments will show the name "Zampala Online" on your statement. Cash payments must be in US dollars. Personal checks from outside the US are not acceptable. International Money Orders from outside the US must be payable in US dollars and have the name of the US Bank where the money order can be cleared printed on the face of the money order. CERTIFICATION STATEMENT AND SHIPPING ADDRESS: I certify I am over 21 years of age and am requesting these sexually oriented materials. I believe the scenes described in any videos I order are within the "community standards" where I live. I certify I am not a city, state, or federal law enforcement officer for the United States nor any other country, nor a postal inspector for any country, nor am I requesting materials as evidence in prosecuting or harassing any individual or organization. Any video sent to me is for my personal use only and will not be shown to minors nor sold, traded or given to others. I have not requested anyone to "protect" me against receiving sexually oriented material nor signed any forms intended to block the receipt of sexually oriented material. If I am ordering from outside the United States, I understand all videos are legal for sale in the USA but that Patches' Place and other represented video producers cannot predict nor be responsible for the actions of customs agents in my country nor any intermediate country. I release Patches' Place and other video producers from any responsibility or liability for the acts, omissions or errors of the government of my country or any intermediate country. I am responsible for any import duties that may be required. Signed ____________________________________ Date __________________ E-Mail address for confirmation or questions________________________ PRINT CLEARLY - Shipments can be sent to PO Boxes within the US Name _______________________________________________________________ Address ____________________________________________________________ City _____________________________ State or Province _______________ Zip _________________ Country (if outside U.S.A.) _________________ Phone number _____________________ (Optional - for use on Express Mail only in the USA.) You can phone your order to Patches' Place by calling 585-218-9928 or send this order to Patches' Place, PO Box 24192, Rochester, NY 14624, USA.