LDTV Order Form Survey

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{LDTV Sports} {LDTV Logo}

If you would like to purchase an LDTV production on DVD please fill out the form below. All copies are $20 each. You can pay by cash or check. Checks should be made out to:
"LRHSD Sunshine Fund"

LDTV
235 Hartford Rd.
Medford NJ 08055
(609) 654-5111 ext.3528

1.	First Name:*

2.	Last Name:*

3.	Street Address:*

4.	City:*

5.	State:*

6.	Zip Code:*

7.	Primary Phone #:* Please enter your phone # in the following format: (xxx) xxx-xxxx

8.	Secondary Phone #: Please enter your phone # in the following format: (xxx) xxx-xxxx

9.	E-mail Address:*

10.

What are you requesting a copy of?*
Since all fields are required please type "N/A" in any field that does not apply.

Name of the production
School(s) involved
Date the event took place
Date that it aired on LDTV
Other

11.	How many copies of the above event would you like?*

12.	How would you like to pay for and receive your copies?* If you are mailing your payment please use the address at the top of the page and make checks out to "LRHSD Sunshine Fund". If you plan to pick up your copies, LDTV will contact you when your order is complete.
	I will pay for my copies when I pick them up at LDTV located at Lenape High School.
	I will mail my payment to LDTV so that they can mail my copies to the above address.
	Other, please specify

13.	Additional Information: