Viewer Dub Request

By Lori Quigley

To request a copy of Channel 3 Eyewitness News please fill out the following form and submit with your payment.


Date: _____________ Time: _____________


Request Taken by: _________________


Name of person requesting:

__________________________________________________

Contact Phone Number:

__________________________________________________


Date Story Aired: ________________Time:________________



StoryTitle/Description:

__________________________________________________________

__________________________________________________________

__________________________________________________________


Reporter: _____________________________


Mailing address/Comments:

_________________________________________________

_________________________________________________

_________________________________________________

$26.50 VHS Payment: [ ] Will be mailed [ ] Will be dropped off

$37.00 DVD Payment: [ ] Will be mailed [ ] Will be dropped off

(Include $2.00 for shipping if you want your copy mailed to you)

[ ] Other _________________________________________

Payment Received: Date: __________________ [ ]

Amount: ___________________

[ ] Check #_______________

[ ] Cash__________________

[ ] Money Order # __________

Please print and mail this form with payment to:

Channel 3 Eyewitness News
1255 E 17th Street
Idaho Falls, ID 83404


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