Please send me the following videos (CA residents please add 9.75% sales tax. WA residents please add 9.5% sales tax). By my signature below, I declare under penalty of perjury and affirm the following: I am at least 21 years of age, I am requesting your materials only for my own personal use in my private residence. I will not exhibit any material you send me to a minor and will carefully insure that no minor has access to it. I personally warrant that the materials I am requesting, to the best of my knowledge and belief contain only descriptions or depictions of sexual activity which are acceptable for adults in my community, based upon the average adult person applying current community standards. Offer void where prohibited by law. Prices subject to change.

Signature ______________________________________________ Date ____________ Age ___________

*PLEASE NOTE: WE CANNOT SHIP TO ALABAMA, ALASKA, ARKANSAS, FLORIDA, HAWAII, IDAHO, JAMAICA, KANSAS, KENTUCKY, MISSISSIPPI, NEBRASKA, OKLAHOMA, TENNESSEE, PUERTO RICO, UTAH, WEST VIRGINA
or any community where XXX material is prohibited or illegal.

WE CANNOT SHIP TO PO BOXES
WE NEED A PHYSICAL STREET ADDRESS THAT IS UPS DELIVERABLE.
WE ONLY SHIP WITHIN THE CONTINENTAL UNITED STATES
Please visit www.AdultDVDEmpire.com - They can ship our titles to areas that we cannot.

All DVD's are value priced at $19.95 each.

Shipping charge for dvds are: $8 for 1-2; $12 for 3-5; $16 for 6-9; $20 for 10-14; $25 for 15-19; $30 for 20-24; $35 for 25-29; $40 for 30-39; $45 for 40-49; $50 for 50 or more

1)_______________________________ 2)_______________________________ 3)_______________________________

4)_______________________________ 5)_______________________________ 6)_______________________________

7)_______________________________ 8)_______________________________ 9)_______________________________

10)______________________________ 11)______________________________ 12)______________________________

Name_____________________________________________________________

Address____________________________________________________________

City/State/Zip________________________________________________________

E-Mail address _________________________________ Phone Number : (_____) ________________________

Quantity =_______ Subtotal =$_________________ Tax (9.75% CA only / 9.5% WA only) =$______________

Shipping =$_______ Total =$_________________ Please allow 2 to 3 weeks for delivery.

I am enclosing my payment by: Personal Check _____ Money Order _____
Please send Checks or Money Orders payable to:
Mancini
PO Box 61264
Seattle, WA 98141-6264
PH: (206) 682-1067 FAX: (206) 682-1336
E-MAIL: mailorder@rodneymoore.com