I, hereby certify by my signature affixed below,that I accept full responsibility for the proper handling,and the return shipment with appropriate insurance (as described fully in FFVRC's instructions) of rental videos. I understand that my membership will be canceled and that I will be liable for replacement costs and lost revenues for the non-return of video(s) and or damage caused by mishandling or tampering. Although tapes damaged or lost in shipment are covered by insurance, I understand that it is my responsibility to report any damaged tapes to the carrier immediately, and to inform FFVRC and to take whatever other steps that may be necessary to file the report (as instructed by FFVRC).

TO THE BEST OF MY KNOWLEDGE, THE TAPES THAT I RENT WILL BE WITHIN MY COMMUNITY STANDARDS. I fully understand the terms of this agreement, and further certify that I am over 21 years of age:

*_____________________________________________________________

• FULL NAME:
• STREET ADDRESS:
• CITY:
• STATE & ZIP CODE:
• E-MAIL ADDRESS:
• SHIP TO ADDRESS IF DIFFERENT FROM ABOVE
• ADDRESS:
• CITY:
• STATE & ZIP CODE:
• CREDIT CARD # AND EXPIRATION DATE: (A refundable deposit of $35. per video to be rented at any one time is required if no credit card is placed on file).
• - - -
• /

TOTAL PAYMENT= $

As no servers are fully secure, fill out and then print (FIRST TWO PAGES) form and send with payment by mail to: F.F.V.R.C.; PMB319; 524 MAIN STREET ; HONESDALE, PA. 18431

*Be sure to sign form.