Order Form

phone: (937) 678-7249  fax: (937) 678-5886

Please complete all information below. MODEL__________________ YEAR____________ ENGINE__________ phone: (937) 678-7249 fax: (937) 678-5886 PART # DESCRIPTION QTY PRICE TOTAL 1) SUBTOTAL (1) (2) PLEASE CALL FOR SHIPPING CHARGES (2) (3) SUBTOTAL (3) (4) OHIO residents: add 7% sales tax to line 3 (4) (5) TOTAL (5) If you need more room, please continue on another sheet of paper, or print out another form. BILLING INFORMATION: Credit Card: VISA MasterCard American Express Discover Card Number: Expiration Date: (MM/YY) Cardholder Name: Billing Address: City: State: Zip Code: County (Ohio residents only) Country Authorizing signature: Date: DELIVERY INFORMATION:   If same as billing information, check here: Name: Day Phone: Company: Evening Phone: Address 1: Fax: Address 2: Email: City: State: Zip Code: Country: Thank you!