Order Form

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P.O. #:__________________(if needed)

Ship To:

Name:____________________________________________________________________________

Company Name:____________________________________________________________________

Address:__________________________________________________________________________

City:________________________________________________ State:___________ Zip: __________

Phone #: (_____)______________________  Fax #: (_____)_________________________________

Email: __________________________

 

Bill To (if different):

Name:____________________________________________________________________________

Company Name:____________________________________________________________________

Address:__________________________________________________________________________

City:________________________________________________ State:___________ Zip: _________

Phone #: (_____)_____________________  Fax #: (_____)__________________________________

Email: __________________________

Payment Metod:

___ Check or Money Order

___ Credit Card (Visa, MaterCard) Please circle type

Name as it appears on card: _____________________________________________

Credit Card Numbrer:_____________________________ Exp.Date:___________ (month/year)

 

 Item  Part #   Qty.  Price (each)  Sub-total
       $  $
         
         
         
         
         
         
         
         
         
         
         
 
               Shipping Charges  
   CA Sales Taxes (if applicable - CA only)  7.875%  
                                       Total  

Raptor 80 Racing