Service Request:

* How will you utilize "Party 101: Consequences"?

I would like to schedule a presentation for my community or organization

Please send a free copy of "Party 101: Consequences"

* What is your intended use of the program? (i.e. who will view the documentary, will it be a group or organization)

Tell Us About Yourself:

* First Name

* Last Name

* Age

* How did you hear about "Party 101: Consequences?"

* Please mark any choices that may apply to you.

* Are you a member of the Parent Teachers Association?

No	Yes, My local unit is

* Are you a member of the Independent Insurance Agents of Texas?

No	Yes, My agency is

Shipping Information:

All DVDs will be shipped via US Postal Service. You should receive your copy of "Party 101: Consequences"
within 1-2 weeks. Please call 1-800-TALK-PTA if you need expedited shipping. There will be a fee for any express delivery services.

Company or Organization Name (if applicable)

* Address 1

Address 2

* City

* State

* Zip

Phone

* Email Address

* Indicates Response Required

Parent or Guardian	Student	Educator or Counselor
School Administrator	Government or Law Enforcement Official	Civic Organization