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Order Form for Rutherford Family Video

  1. Print this page.
  2. Fill it out.
  3. Enclose a check payable to "FMS Foundation" to pay for the tape and shipping and handling.
  4. Mail to FMSF Video, Rt. 1 Box 510, Burkeville, TX 75932
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              V I D E O   T A P E   O R D E R   F O R M
                                 for
                "W H E N   M E M O R I E S   L I E...
              T H E   R U T H E R F O R D   F A M I L Y
                 S P E A K S   T O   F A M I L I E S"

Mail Order To:
  FMSF Video
  Rt. 1 Box 510
  Burkeville, TX 75932

                                   DATE:   /   /

Ordered By:                        Ship to:





Please type or print information:
+--------+-----+------------------------------------+-------+--------+
| QUANT- |  #  |            DESCRIPTION             | UNIT  | AMOUNT |
|  ITY   |     |                                    | PRICE |        |
+--------+-----+------------------------------------+-------+--------+
|        | 442 | The Rutherford Family              | 10.00 |        |
|        |     |               Speaks to Families   |       |        |
+--------+-----+------------------------------------+-------+--------+
                                                   SUBTOTAL |        |
                                                            |        |
                                                            +--------+
                                    ADDITIONAL CONTRIBUTION |        |
                                                            |        |
                                                            +--------+
                                                  TOTAL DUE |        |
                                                            |        |
                                                            +--------+

U.S. Shipping & packaging charges are included in the 
price of the video.

FOREIGN SHIPPING AND PACKAGING
  Canada                $4.00 per tape
  All other countries  $10.00 per tape.

Allow two to three weeks for delivery. Made all checks payable to FMS
Foundation. If you have any questions concerning this order, call
Benton, 409-565-4480.

The tax deductible portion of your contribution is the excess of goods
and services provided.

                     THANK YOU FOR YOUR INTEREST
**********************************************************************

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