Independence 72 Media Event Page Our Sponsors Media Request / Order Form Please fill out this form to request or order media. Performers, Sponsors and Members will receive (1) Free Event DVD. You can buy additional Event DVD, Blu-Ray or Photo CD. First Name (required) Last Name (required) Contact Number (required) Email (required) Email (Verify) (required - * must match email above) I Am A: (required) —Please choose an option—PerformerSponsorMember Performers, please enter the name of your choreograph: (required) Sponsors, please enter the name of your company: (required) Mailing Address: Address #1 (required) Address #2 City (required) State (required) —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code (required) Additional Order Form: * If you are not purchasing additional media, leave this section blank and proceed directly to the submit button. By filling out the form above, you will receive 1 Free Event DVD. Purchase additional copies below by entering the Media Type and Quantity. Available formats include: Blu-Ray $22 / Event DVD $10 / Photo CD $10 ($10 shipping & handling is included in the price) Blu-Ray $22 Blu-Ray $22 Blu-Ray Quantity: (required) Event DVD $10 Event DVD $10 Event DVD Quantity: (required) Photo CD $10 Photo CD $10 Photos (CD) Quantity: (required) [hidden blurayhid “Blu-Ray”] [hidden eventdvdhid “Event DVD”] [hidden photocdhid “Photo CD”]