Non-Credit Videotape Reservation Request

If you plan to make a credit card payment, please print out this form and mail or fax it to ICLE.
Unfortunately, we are not able to accept online credit card payments at this time.

Name
Georgia Bar Number
Firm Name
Suite/Floor Number
Street Address (Necessary--Delivery is provided by UPS)
Street ZIP (ZIP+4)
City
State
Daytime Phone (xxx) xxx-xxxx
Program Format (VHS or DVD) where applicable
Program Name
Please list a 1st and 2nd choice
of reservation dates for this program.
Your 2nd choice date MUST be at LEAST
14 days after your 1st choice date.
Reservation as soon as possible
1st Choice Date
2nd Choice Date
I have enclosed a check, payable to ICLE in GA for $
Check Number
I authorize ICLE to charge my
____MasterCard ____VISA

____AMEX ____Discover account for the following amount:

$____________________________

Account Number:____________________________
(Please include the Credit Card Verification Number: A three-digit number usually located on the back of your credit card; *AmEx is a four-digit on the front of the card.)

Signature:_____________________________________________

Expiration Date:___________________________

Please fax your request to (706) 369-5899, or mail to:
ICLE in Georgia
P.O. Box 1885
Athens, GA 30603-1885