SUBMISSIVE JESUS ORDER FORM
If ordering by Check or Money order: print, fill out and mail the order form below

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ITEM  QTY. PRICE
Yes, I want my Submissive Jesus.  Gimme.  Gimme.  Gimme!!!  Praise the Lord! 
_____ $
Add shipping and handling
$
TOTAL

$

How did you hear about us? Please circle one:
My Space   Google   YouTube   Livevideo   Brightcove   Pirromount Website
Metacafe   Atheist Website   Religious Website   Friend   Other

Shipping & Handling charges : $12, each additional unit add $8
FOREIGN SHIPPING $25

PLEASE PRINT CLEARLY

 Name_________________________________ Address_______________________________

 City___________________ State_________________ Zip___________ Country________________

 Phone Number___________________________

To order, send check or M.O. to:

Submissive Jesus Prayer Answering Talking Head
c/o Pirromount Pictures
P.O. Box 7520
Van Nuys, California 91409

We try to ship orders immediately, but things do back up so please allow two weeks for delivery.

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