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Any Additional Address Information:

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How many DVDs are you purchasing:

Number of DVDs x $35 = Total Amount Enter that amount in one of the boxes below

Check Payment Method
Check Number:	Total Amount:

If you are choosing to pay by check please make it out to and mail your check to: Love2Dance, Inc., 112 Chapel Ridge Circle, Myrtle Beach, SC 29588

Credit Card Payment Method (if you're using a credit card please choose from below)  Master Card        Visa        Discover        Telephone

You may also pay with a Credit Card by telephone - (843) 215-1152. Just fill out the online form but leave the credit card information empty. Then give Carolyn & Rick Robinson a call and give them your credit card information over the telephone. Please select 'Telephone' as your choice above and call Carolyn & Rick ASAP

Bank Card Type:   Credit      Debit
Card Number:	Exp. Month: MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	Year: Year2008 2009201020112012201320142015201620162017
Exact Name on Card:		SVC #:
Total Amount On Card:

Please be sure that the mailing address you entered above is the actual correct mailing address for the bank card you are using! The address needs to be correct in order for the card transaction to process!

The e-mail that is created and sent by this form goes to E-mails Servers that are H.I.P.A. (Health Information Protection Act) compliant. H.I.P.A. requirements insist that there be a 128 bit encryption in all e-mails coming and going from the servers.