Fax/Mail Order Form
Ship To:
Full Name:
Address:
City:
State/Province:
Postal Code:
Country:
Payment:
Card Type:
Visa   MasterCard   Discover   AmEx
Full Name: (as shown in the card)
Card Number:
Expiration Date (MM/YYYY):
/
Signature:
By signing, I certify that I am 18 years or older and of legal age in my country/locale of residence to purchase the products sold on this store. I agree to pay the total amount for all products purchased.
Contact:
Email Address: (required)
 Phone: (optional)
Items:
Product Name Option
(NTSC, PAL, DVD)		 Price Quantity Total
$ x = $
$ x = $
$ x = $
$ x = $
$ x = $
$ x = $
Promotional Code? If you have a promotional code write it below and apply the discount to the sub-total:

Please calculate your order total carefully. Any errors or invalid information will delay processing of your order.
 Sub-Total: $
 Express shipping (USA only) add $17.50: $
Promotional code discount (see info on left): $
USA: ME residents add 5.0% sales tax: $
Order Total (USD): $
To Submit your Order...
By Fax:
  1. Complete the form, including the credit card payment information and signature.
     
  2. Fax the form to: +1 207-761-2822
By Mail:
  1. Complete the form and sign the appropriate field above.
     
  2. If you are paying by credit card complete the payment information above, otherwise include a check or money order for the total amount.
    Note: If you live outside of the USA and you are paying by check; You must send a bank cashier's check in US$ funds and drawn in a US bank account. You can purchase this type of check at your local bank.
     
  3. Mail the form to:
     
    BCPI
    PO BOX 7612
    PORTLAND, ME 04112
    USA