Print this form and mail it to:

Independent Cinemas

7270 South Broadway

Red Hook, NY 12571

 

Your information:

Name:  
Address:  
City:  
State:  
Zip:  
Phone Number:  

 

Ship to: (if different from above)

Name:  
Address:  
City:  
State:  
Zip:  

 

Please include a check in the amount of $50.95 written to: "Lyceum Cinemas".  Checks must

be signed and include a current address and phone number.