Dub Request
Viewing Copies 		Infomercial Monitoring Service, Inc.
Satellite II - 810-812 Parkway - Broomall, PA 19008
p • 610.328.6902 - f • 610.328.6791
Please fill out the following form to submit a dub request. If you do not wish to use this electronic form
you may print and fax it to 610-328-6791. To speak with an IMS representative call 610-328-6902.
Please provide the following contact information:
Name:
Company:
Address:
City:
State:
Zip / Postal Code:
Country:
Phone Number:
Fax Number:
Email Address:
Website:
Infomercial / Spot Title:
Description:
Length:
Dub Format:
Quanity:
Credit Card Type:
Cardholder Name:
Credit Card Number:
Expiration Date:
Ship Via:
Shipping Method:
Shipping Number:
(If no shipping number is provided, we will charge your credit card for the shipping costs)
Remarks: