(Please Print Form)

BCT Video Order Form

Name of Program__________ Date Program Recorded___________

How Many Copies Wanted ______

Format Wanted DVD or MPG4 File _________

Contact Name __________________

Address ________________________________________

Phone Number ___________________________________

Email Address ___________________________________

Send a $10.00 (per copy) check to:

Village of Bolingbrook

375 W. Briarcliff Rd.

Bolingbrook Il. 60440

Allow 2 weeks for processing. We will mail the video to you.