ORDER FORM

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Living Media India Limited
A-1, Hamilton House, Connaught Place,
New Delhi -110001
India

Date____________

Please arrange to send me the following Audio Tapes/ Compact Discs:

Catalogue No Title name Audio Tapes(Nos) CDs (Nos) Value
         
         
         
         
         
         
Total        

 

My particulars (In Capital letters)

Name ____________________________________________________________

Address_________________________________________________________

Country_________________________________

Tel number_____________________

My email_________________________________________________________

a)Cheque/ Draft no ______________________________________________________

drawn on _____________________________________________ (Name of Bank)

for Rs ____________________________________ in Favour of Living Media India Ltd.

OR

b)Please charge my Credit Card

˜ Mastercard ˜ Visa ˜ American Express

Credit Card no :˜ ˜ ˜ ˜ ˜ ˜ ˜ ˜ ˜ ˜ ˜ ˜ ˜ ˜ ˜ ˜

Card Members name ___________________________________________________________

Card members signature_______________________________________

Card expiry date ______________________________________________

Please deliver the cassettes and /or CDs ordered by me to:

Name _____________________________________________

Address____________________________________________

Country, PIN/ZIP _____________________________________

Tel number_________________________

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