MEDIUM PRODUCTIONS
Order Form

by Fax or Post

once your account has been established you may then use this form for e-mail orders using your password

Fax your order below directly to Medium Productions (0)1708-640291

including your credit card details

Call any day (including weekends) ANYTIME

Please write clearly using BLOCK CAPITALS only so that we can process your orders without delay

Alternatively, you can post it to:

Medium Productions Purchases

74 Saint Lawrence Road, Upminster, Essex RM14 2UW England

We can accept:

Visa, Mastercard and JCB Card

Please fill in the Order Form below. Include item description or title, catalogue number and specify format (i.e. CD, Cassette, Video, T-shirt, etc.). Please note, if you are paying for merchandise at the Medium Subscribers rate you MUST enter your membership number in the space provided. This form may also be used if you are paying by cheque/postal order/money order, (payable to MEDIUM PRODUCTIONS LTD.). or cash. Simply fill in the necessary sections, (ignoring the credit card surcharge) and post it to the address above.
Product
Format
Price
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Merchandise Subtotal
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Postage / Handling
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Total
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Credit Card Surcharge, add 5%
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GRAND TOTAL
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Name:
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Membership No.
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Address:
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City:
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State:
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Post Code / Zip:
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Country:
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Phone Number:
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E-mail Address:
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Card Type:
ie vsia /mastercard
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Please state if
chargecard ie Delta
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Card Number:
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Expiry Date:
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Password:
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(note) writing in a password of your own choosing will allow you to do future
orders by e-mail substituting your password for your credit card #
Billing Address if different from above
Address:
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City:
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State:
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Post Code / Zip:
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Country:
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Signature:
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Date:
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H O M E P A G E
C A T A L O G U E