Video Order Form - Clark-Vancouver Televison

Program Request Form

Make checks payable to: City of Vancouver

Mail payment to:

City/County Cable Television Office
Attn.: CVTV/Dub Request
PO Box 8995
Vancouver, WA 98668-8995

Contact our office at: 360-487-8703, 202 E. Mill Plain Blvd., Vancouver, WA 98660.

Price and format (includes shipping, handling and 8.2% sales tax):
$28 for VHS ($23.11 + $2.77 s/h + $2.12 sales tax)
$25 for DVD ($21.29 + $1.81 s/h + $1.90 sales tax)

Please complete the information below and return along with your program request. Your order will be processed and mailed within five business days.

Thank you.

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Name:
Mailing Address:
City:	State:	ZIP:
Daytime Phone Number: E-mail Address:

For internal use ONLY

Date Received:____________________ Date Mailed:____________________ Staff Initials:_______

Program Number:___________________ Revenue Code: 655.000000.341695.0000.000000

Program Title/Description		Program Date	Format (VHS or DVD)	Quantity	Cost
Remove	Smart Environments: Artificial Intelligence at Home and Beyond	11-14-08	VHS DVD
Total Remitted:					$