Please provide the following contact information: (fields marked with * are required)
*Students Name
Organization
*Street Address
Address (cont.)
*City
*State/Province
*Zip/Postal Code
*Country
 *Phone
E-mail
Please select desired product(s):
*QTY *DESCRIPTION (multiple choices allowed by holding Shift and clicking left mouse button)
PAYMENT 
*if paying by check or money order, please print out  this completed form
and remit along with payment to:
Galis Photography & Video Inc.
850 Rte 1 No. 3rd Floor
North Brunswick, NJ 08902
(make check/money order payable to Galis Photography & Video Inc.)
 *Method of Payment

*Credit Card
*Cardholder Name
*Card Number
*Expiration Date
*V-Code (Last 3 -Digit Number on Back of Credit Card)



Ship Product(s) - (if "yes", add $10 s/h per item - select "no" to p/u your item at event location)              

Yes
No

 

SHIPPING INFO     same as above
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
 
Would you like to receive further information on Galis products and services?

Yes No