Online Video Request Form

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To purchase the video, please make checks payable to the City of Fairfax and send to: Cityscreen-12
10455 Armstrong Street
Fairfax, VA 22030
Please correct the field(s) marked in red below:

*Indicates Required Information

First Name:
 *
Last Name:
 *
Street Address:
 *
City:
 *
State
 *
Zipcode
 *
Daytime Phone: (xxx-xxx-xxxx)
 *
E-Mail:
 *

Name of Program or Date of Meeting

 *
Cost for purchase Blu-ray is $20 or DVD is $15 per copy:
Blu-ray (Quantity) DVD (Quantity)
For Purchase
For Loan
  1. To receive a copy of your submission, please fill out your email address below and submit.