Print and complete this form to send with your tape(s).

Please Convert From: PAL SECAM NTSC unknown (please check only one) PAL-M PAL-N MESECAM

Please Convert To: PAL SECAM NTSC

Return Address: (we cannot ship to PO boxes) Name or Business __________________________________________ Street ____________________________________________________ City _______________________ State _____ Zip ______________ Home Phone __________________ Work Phone __________________

Billing Address: (if different from Return Address) Name or Business __________________________________________ Street ____________________________________________________ City _______________________ State _____ Zip ______________ Home Phone __________________ Work Phone __________________

Form of Payment:   Visa Card Number: __________________________ Mastercard Expiration Date: _____________ American Express CVV Number*: _________________ * CVV is an anti-fraud security feature to help verify that you are in possession of your credit card. For Visa, Mastercard and Discover cards, the three-digit CVV number is printed on the signature panel on the back of the card immediately after the card's account number. For American Express, the four-digit CVV number is printed on the front of the card above the card account number.

Personal Check Please include check or money order with tape(s). Make checks and money orders payable to "Quantum Star" Money Order