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PERSONAL CONTACT INFORMATION

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* denotes a required field

* Name:

* Address:

* City, State, Zip:

* Phone Number:

* Email Address:

* Program Name/Date Aired (if applicable):

* Program Description (if applicable):

PAYMENT INFORMATION

* Payment Amount & Media Type:

$ 18.00 WKTV provides VHS Tape
$ 10.00 You provide VHS Tape
$ 18.00 WKTV provides DVD-R
$ 10.00 You provide DVD-R
$ 20.00 Cage Fights VHS*
$ 20.00 Cage Fights DVD-R*

* Please specify which date you want for the Cage Fight in the Program Description above.

* Payment Type:

note:
***if you chose CASH or CHECK as your method of payment, you will need to drop that off, in person, to the WKTV broadcast studios in Wyoming, Michigan.

***if you chose a credit card as your method of payment, you will need to fill in the appropriate information below.

FOR CREDIT CARD PAYMENTS ONLY

Credit Card #:

Expiration Date:

Security Code:

Card holder's name:

CREDIT CARD BILLING ADDRESS INFO

** only if paying with a credit card & is different from contact information provided above **

Name on card:

Address:

City & State:

Zip & Country

I certify, under oath, that I am the legitimate card holder of record

ADDITIONAL COMMENTS

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Refer to our privacy policy for any questions you might have regarding the information you submit to WKTV.