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or mail to
For those of you who don't trust computers, email or giving your Credit Card information online...We understand.
But our Secure Order site is totally protected with 128-bit ENCRYPTION by YAHOO!
You may either Print this page or copy and paste to your own text or word processor program, print it, then fill it out and Fax back to us.
First Name________________________Last Name_________________________________
Billing Address
Street____________________________________
City______________________________________
State______________Zip Code________________
Telephone (______) _________-_____________
Cell Phone (______) _________-_____________
E-Mail _________________________________________________________________
Check Here if Billing same as Shipping [____]
Shipping Address (if different than Billing Address)
Street_____________________________________
City_______________________________________
State______________Zip Code________________
Order Information
QTY________Item Description____________________________Part #_____________
QTY________Item Description____________________________Part #_____________
QTY________Item Description____________________________Part #_____________
QTY________Item Description____________________________Part #_____________
Credit Card Information
Type of Card (Visa-MasterCard-Discover)___________________________
Card # _______________________________________________________
Exp. Date __________/__________ CCV#__________3-digit code on back of card
Month Year
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