PATCHES' PLACE ORDER FORM (revised 04/23/12) Please circle format wanted: NTSC PAL (NOTE: NTSC is the format used in North America and Japan and PAL is used in most other countries. All VHS sales have been phased out.) Please check each item that applies: DVD ___ Pee Play 1: Pee Party Pleasures w/4 girls ($50.00) ... $________ ___ Pee Play 2: Kinky Wet Girls w/4 girls ($50.00) ....... $________ ___ Pee Play 3: Girls Just Wanna Have Fun ($50.00) ....... $________ ___ Pee Play 4: Wet Girls Gone Wild w/3 girls ($50.00) ... $________ ___ Pee Play 5: Strange Behavior w/5 girls ($50.00) ...... $________ ___ Patches 10 w/ Jennifer and Melissa ($50.00) .......... $________ Patches 14 (No longer available - VHS discontinued) Patches 15 (No longer available - VHS discontinued) Patches 16 (No longer available - VHS discontinued) ___ Patches 17 Five girls ($50.00) ....................... $________ ___ Patches 18 Five girls ($50.00) ....................... $________ Patches 19 (No longer available - VHS discontinued) Patches 20 (No longer available - VHS discontinued) Patches 21 (No longer available - VHS discontinued) Patches 22 (No longer available - VHS discontinued) Patches 25 (No longer available - VHS discontinued) ___ Patches 26 Three girls ($50.00) ...................... $________ ___ Patches 27 with Jennifer ($50.00) .................... $________ ___ Patches 28 Just Jen ($50.00) ......................... $________ ___ Patches 29 Four girls ($50.00) ....................... $________ Patches 30 (No longer available - VHS discontinued) ___ Patches 31 Four girls ($50.00) ....................... $________ ___ Patches 32 Three girls ($50.00) ...................... $________ ___ Patches 33 Five girls ($50.00) ....................... $________ ___ Patches 34 Two girls ($50.00) ........................ $________ ___ Patches 35 Four girls ($50.00) ....................... $________ ___ Patches 36 Three girls ($50.00) ...................... $________ ___ Patches 37 Five girls ($50.00) ....................... $________ ___ Patches 38 Six girls ($50.00) ........................ $________ ___ Patches 39 Six girls ($50.00) ........................ $________ ___ Patches 40 Six girls ($50.00) ........................ $________ ___ Patches 41 Six girls ($50.00) ........................ $________ ___ Patches 42 Four girls ($50.00) ....................... $________ Patches 43 (No longer available - VHS discontinued) ___ Patches 44 Three girls ($50.00) ...................... $________ Patches 45 (No longer available - VHS discontinued) ___ Patches 46 Four girls ($50.00) ....................... $________ ___ Patches 47 Three girls ($50.00) ...................... $________ ___ Patches 48 Four girls ($50.00) ....................... $________ ___ Patches 49 Six girls ($50.00) ........................ $________ DVD BD ___ ___ Patches 50 Two girls ($50 for DVD, $70 for BD)* $________ ___ ___ Patches 51 Three girls ($50 for DVD, $70 for BD)* $________ ___ ___ Patches 52 Three girls ($50 for DVD, $70 for BD)* $________ ___ ___ Patches 53 Four girls ($50 for DVD, $70 for BD)* $________ ___ ___ Patches 54 Four girls ($50 for DVD, $70 for BD)* $________ ___ ___ Patches 55 Five girls ($50 for DVD, $70 for BD)* $________ ___ ___ Patches 56 Four girls ($50 for DVD, $70 for BD)* $________ * BD is the abbreviation for Blu-ray Disc Credit Card orders - add $3.00 per video service charge $___________ Australian orders paid by credit card will have a 10% GST tax added to their total .................... $___________ Shipping is free but 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. (Optional) $___________ 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 - Name _______________________________________________________________ Address ____________________________________________________________ City _____________________________ State or Province _______________ Zip _________________ Country (if outside U.S.A.) _________________ Phone number _____________________ (Optional - for use on Express Mail only.) 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.