Independence 72 Media – Sri Lanka America Association of Las Vegas

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 (Verify)

(required - * must match email above)

I Am A:

(required)

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)

Zip Code

(required)

PayPal - SLAALV

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

Blu-Ray Quantity:

(required)

Event DVD $10

Event DVD

Event DVD Quantity:

(required)

Photo CD $10

Photo CD

Photos (CD) Quantity:

(required)

[hidden blurayhid “Blu-Ray”] [hidden eventdvdhid “Event DVD”] [hidden photocdhid “Photo CD”]