KineticTalent.com
Image Scanning Order Form
Please print out this form and include it with your images
when you deliver it to our office.
MemberID:
Last Name First Name
Name:
Address:
 Apt./Suite:
City:
 State: Zip:
Day Phone:
Eve. Phone:
eMail:
If you HAVE images on disk:
 
Number of Images to Upload:
 
x $5/ea.
SubTotal
TN State Sales Tax (9.25%)
Total
Image Names On Disk:  
Photographer:
Date Taken:
 
Please make checks payable to "KineticMedia.com"