I CERTIFY BY MY SIGNATURE BELOW, UNDER PENALTY OF PERJURY,  THE FOLLOWING:

    I am an adult, over 21 years of age.   I am freely entering into this purchase in the capacity of a private citizen.   I am not in any way connected with, employed by, acting on the behalf of, or at the request or suggestion of any Federal, state or local law enforcement or information gathering agency, or of the U.S.  Postal Inspection Service.    The videos I am requesting will not be used as evidence in any criminal investigation, or for the purposes of entrapment or prosecution against any person whomsoever.   I have never requested that my name be put on any list compiled by the U.S. Postal Service, or any governmental or private agency which would expressly forbid me from receiving sexually oriented materials through the mails, or through other channels.   I believe in the First Amendment's guarantee of free speech.   I  believe my standards accurately reflect those of the community / zip code in which I reside, or in which I choose to receive shipments which are of a sexually oriented nature.   I further certify that the videos I am purchasing are for my sole and personal possession and use, and are for my educational or entertainment purposes only, and shall not be shown to minors or to other persons who might find the subject matter to be personally offensive.

Printed or typed name:_____________________________________
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Legal signature:__________________________________________
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Date signed:_____________________________________________
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Street Address:___________________________________________
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City, State, Zip Code:______________________________________

E-mail: __________________________________________________

Title: ( PLEASE indicate DVD or VHS tape )                       Price:
*If you do not indicate DVD or VHS, you will receive DVD*

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                                                                                             Shipping:

 ( $7.00 for the first video,  $1.00 each additional)                  ____________

                                                                  Total:                  ____________