VIDEO BOOKING FORM

This form is designed to be completed, printed and posted/faxed with payment. Invoices can only be issued if a Purchase Order is supplied. Up to three titles may be requested at any one time.

Post: Family Planning Queensland, PO Box 215, Fortitude Valley, Qld 4006
ABN 61 009 860 164
Fax: 07 3250 0292

Contact Details
Date:
Contact Name:
organisation
postal address
Phone:		FAX:
EMAIL:		MOBILE:
video title (s)	1
	2
	3

Administrative Fee: $15.00 per week ( inclusive of GST, postage and handling)
Method of Payment: Cash, Credit Card, Cheque or Company Purchase Order are acceptable methods of payment. Organisations may request an invoice upon supply of a purchase order.

Payment details
paying by:
cHEQUE	For $ enclosed
CASH	For $
INVOICE	Order Number: (Company Purchase Order must accompany this form)
CREDIT CARD	Visa Mastercard Bankcard
	Credit Card Number:	3 digit security no:
	Name on card:	Expiry Date:
	Signature:____________________________________________Please debit: $