fax or mail this form                           

			   AM TECH VIDEO, INC.
 			    6585 Smith Road.
			Cleveland, OH 44142-3716
			     (216) 676-0441
		   	Fax: (216) 676-0838
			      800-262-8723
    
    First Name:____________________________ 
     
     Last Name:______________________________________

Street Address:____________________________________________
    
          City:_________________________________

         State:_____

           Zip:_______

       Country:_________________

       Phone #:_________________


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  Tape Purchased:______________________________________
  
  Payment Info:  ___ Check   ___ Credit Card  ___ Money Order
  
  Credit Card information

  Card Type: ____ Mastercard  ____ Visa  ____ American Express

  Name on card: __________________________

  Card Number: _____________________________

  Expiration Date: _______________

  Signature: X__________________________