MediaShelves.com FAX Form

Please print and fill out this form so that we may process your inquiry or order.

You may FAX the filled out form to: 206.784.0811

Or send this form to us at: MediaShelves.com | 4611 11th Avenue N.W. | Seattle, Washington 98107

Ordered by:
Name:_______________________________ Date:______ Company:__________________________
Address:________________________________ City:____________________ State:____ Zip:______
Daytime Phone:______________ Evening Phone:______________ Email:________________________

Shipping Info (if different from ordered by info):
Name:_______________________________ Company:__________________________
Address:________________________________ City:____________________ State:____ Zip:______
Daytime Phone:______________ Evening Phone:______________ Email:________________________

Media Storage Shelves - CD/DVD/VHS (Free Standing): (check web for current prices)
Qty. Item
Qty. Item
Qty. Item
____  60" x 24"
486 CDs/216 DVDs/132 VHS		 ____  48" x 24"
378 CDs/180 DVDs/110 VHS		 ____  36" x 24"
270 CDs/128 DVDs/78 VHS
Item Total $:_________

DVDRacks & VHS Video Cabinets (Table Tops): (check web for current prices)
Qty. Item
Qty. Item
Qty. Item
____  28 1/2"x12"
(51 DVD or 30 VHS)		 ____  28 1/2"x24"
(108 DVD or 66 VHS)		 ____  19 1/4"x12"
 (34 DVD or 20 VHS)
Qty. Item Qty. Item Qty. Item
____  19 1/4"x24"
(72 DVD or 44 VHS)		 ____  10"x12"
(17 DVD or 10 VHS)		 ____  10"x24"
(36 DVD or 22 VHS)
Item Total $:_________

CD Cases (Table Tops): (check web for current prices)
Qty. Item
Qty. Item
Qty. Item
____  19 1/2" x 12"
(75 CD's)		 ____  19 1/2" x 24"
(162 CD's)		 ____  13" x 12"
(50 CD's)
Qty. Item Qty. Item Qty. Item
____  13" x 24"
(108 CD's)		 ____  7"x12"
(25 CD's)		 ____  7"x24"
(54 CD's)
Item Total $:_________

Method of Payment:
Please charge my: Mastercard Visa
Card Number:_________________________________ Expiration Date (Month/Year):_________
Signature (as shown on credit card):______________________________________________
If paying by another method other than credit card, please indicate: Check Money Order