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CUSTOMER INFORMATION |
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NAME |
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Tel # |
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ADDRESS |
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Unit |
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CITY |
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Zip |
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No deliveries to P.O. Box. Must be same as billing address |
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CARD INFORMATION |
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CARD # |
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Expires |
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CVV2 # |
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CVV2 = LAST 3 DIGIT CODE AFTER ACCOUNT # AT THE BACK OF THE CARD ON SIGNATURE BOX |
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VEHICLE INFORMATION |
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MODEL
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SERIES |
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VIN # |
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Prod. Date |
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Quantity |
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DESCRIPTION |
UNIT |
AMOUNT |
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SUBTOTAL |
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TAX |
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HANDLING |
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SHIPPING |
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TOTAL |
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PLEASE FAX TO: 1 323 755 1176
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FOR CARD ORDERS: I have read and accept the terms and conditions for this order and sale. I agree to pay the total amount according to Card Issuer Agreement. Orders cannot be shipped without this signed form. Shipping charges will be added. SIGNATURE: Drivers Lic. # |
Thank you for your order.
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