Please E-mail or print and mail the following information:

Name:

Address:

City: 

State:

Zip Code:

Daytime Phone: 

Evening Phone:

Email address:

Are you certified to receive Free Matter for the Blind or Handicapped?

Yes____________      No____________

Please send the following movie as my free 1st rental:

Best way to contact me is (circle 1)by: phone   email   mail

Enclosed is my check for $20 to cover the required one time membership fee and the first video rental. I have read the terms of use and agree to its provisions. I understand that I can prepay for additional movies at the rate of $3.oo per film (plus $.22 tax within California)

Signature:                                                           

Date:

Mail completed form with check to:                                 

Blue Rose Video

397 Holly Drive

San Rafael, CA 94903