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

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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      Discover

Card Number: Expiration Date: (MM/YY)

Cardholder Name: CVV2 (Security Code)

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!