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Mail Order Form

To order by Mail:

Print this order form
Fill out and sign this form.
Make check or money order payable to: Unlimited Media
Mail to:
Unlimited Media
c/o The Lorissa McComas Fan Club
2130 Paul Drive
Columbus, OH 43211-1750

Print this form and mail with your payment, you must sign the adult verification form and include all shipping.

If you are ordering an Online Membership to My Private Room, select a term below:

Desired Username and Password:

1 month $14.95

3 month $39.95

At this time we are not offering recurring memberships. Our memberships automatically expire. There is no need to cancel. Please make sure you include your email address below!

Quantity:	Item #:	Price Each/Total Price:





SubTotal:
Shipping:
Shipping and handling: $5.00 for the first item $.50 each additional item. Orders with insufficient shipping cannot be shipped. Payment must be in U.S. Funds. PLEASE INCLUDE YOUR EMAIL ADDRESS, so that we may contact you if needed.
Grand Total

Adult Release Form

This material is intended for adults only
To place an order, you must provide your full name, residence and date of birth, as well as your signature.

Full Name:	______________________________________________________
Email:	______________________________________________________ (format: jdoe@home.com)
Telephone:	______________________________________________________ (include area code and/or country codes)
Address:	______________________________________________________
City, State, Zip	______________________________________________________
Date of Birth:	______________________________________________________
Signature:	_____________________________________ Date: ___/___/____

By signing and dating this Release Form, you hereby attest that the information is true and correct. Failure to provide correct information as to your true name and birthdate will result in the cancelation of your order and the immediate refund of all money included.

Please contact with questions or comments.

[Lorissa.com Home Page]

Mail Order Form

Adult Release Form

This material is intended for adults only To place an order, you must provide your full name, residence and date of birth, as well as your signature.

This material is intended for adults only
To place an order, you must provide your full name, residence and date of birth, as well as your signature.