Chessie Moore's Online Order Form
Order with a US postal money order or cash and get a 10% discount
(discount not valid with any other special)

Just print this page then fill it out and mail to the address below.

ALL Overseas orders require a money order and check in US funds only. 
Mail to the address below and include a shipping label.

Chessie Moore
POB 375 Larned KS 67550


Today's Date:


First & Last Name:


Internet Email Address:


Street Address (1):


Street Address (2):

City, State ZIP


Country:


Daytime Phone Number:


Evening Phone Number:


What type of Payment will you be using?

Visa________Mastercard_______ Check______ Money Order______

***US FUNDS ONLY***

Credit Card Number:


Expiration Date:


Name On Card:



Please enter the items you want to order here.  


(1)Item#:

Description:

Quantity:



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How would you like your order shipped?

______Cont. US - USPS Priority Mail (Free)
______International - Global Priority ($10.00/per tape)



Are you 18 years of age or older?
___I am not 18 years of age or older, cancel my order!
___I am 18 years of age or older, send my order!


I declare that I am an adult, 18 years of age or older and
am lawfully entitled to receive sexually explicit materials in the community
where I live and through my mailing address. I understand that I am purchasing/requesting
materials which are of a sexual oriented nature. I believe this material
to be within community standards of the area in which I live. I authorize
Chessie Moore Online, to send materials purchased/requested to me at
the address listed below. I have not requested the US Postal Service or
anyone else to protect me against the receipt of sexually oriented materials
or advertisements. I am not an agent or employee of the US Postal service
or any government agency ordering/ requesting materials for the purpose
of entrapment. I have absolutely no desire to purposely or accidentally
receive or request any material of any nature which can be considered illegal
or obscene in any form, including but not limited to, brochures, catalogs,
photos or videos. I feel that I am an average American citizen or person
in the USA with the right to view adult oriented material of any legal
type in the privacy of my home. I agree to not duplicate materials for
commercial purposes. I certify under penalty of perjury that the information
is true and correct to the best of my knowledge and that the use of a fictitious
name and signature does not abdicate me from the above.





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SIGN HERE                                                                 DATE