SURFACE ORDER FORM

Juliet Heart, PO Box 3997
Silverdale, WA 98383-3997 USA

Please use this form if you wish to pay by personal check, money order or cash. To print this form, simply click on your "Print" feature. Please send this order form to the above address. Make Checks/Money Orders payable to Juliet Heart.

I certify that I am at least 18 years old.  I am aware that you are sending me sexually oriented material which is only for my use and will not be resold or in any way be distributed -- especially to minors.

PLEASE PRINT CLEARLY! IF WE CAN'T READ YOUR NAME OR ADDRESS WE WILL NOT SHIP THE MATERIAL.

FIRST NAME: _____________________ LAST NAME: _____________________________________

STREET ADDRESS: _________________________________________________________________

CITY: ____________________________ STATE: _________________ ZIP CODE: ______________

EMAIL ADDRESS: __________________________________________________________________

Signature:___________________________________________________
(Needed for Disclaimer. Without this signature we WILL NOT send any orders).

Personal Check Enclosed___________  (Order held until check clears) (US FUNDS ONLY).
Money Order Enclosed_____________ (US FUNDS ONLY)
Cash Enclosed___________________ (Not recommended to send Cash in the mail)
Make check/money orders payable  Juliet Heart.

Please send the following items. (List I.D. Letters and Numbers i.e.: DD-01 etc etc)
___________________________ Price ________________
___________________________ Price ________________
___________________________ Price ________________
___________________________ Price ________________
___________________________ Price ________________

DVD ONLY: Please select Custom Jewel Case or Plain Jewel Case (Please circle your choice)

Sub-Total: ________________________

Shipping & Handling: ________________ (U.S. $6.00 First DVD and $2.00 Each Additional DVD)

OVERSEAS: $12.00 first DVD, $2.00 each additional DVD.

Washington State Residents ADD 8.6% Tax: _________

Total of Order Enclosed: $_________________________