Your Name:

Customer ID #:

Shipping Address Street Address: City: State: Zip Code:

Mailing Address Address: City: State: Zip Code:

Telephone (Day): Telephone (Evening):

Year, Make, and Model of Vehicle: Engine Size:

PART #		QTY	DESCRIPTION	PAGE #	EACH	TOTAL
1
2
3
4
5
	MERCHANDISE TOTAL:
	PA ONLY: 6% SALES TAX:
	SHIPPING & HANDLING:
	COD CHARGE $9.00:
	TOTAL AMOUNT DUE:

Credit Card Type:	MasterCardVisaAmExDiscover
Credit Card Number:
Credit Card Expiration:
Comments:

Shipping & Handling:	Under $20: $5.95	$20-$49: $6.95	$50-$79: $7.95	$80-$109: $8.95
	$110-$149: $9.95	$150-$199: $10.95	$200-$299: $11.95	$300-$399: $13.95
	$400-$499: $15.95	$500-$599: $17.95	$600 and up: $19.95

• Shipments outside the continental US can be sent by US Air Mail or UPS – Shipping is $2 plus postage.
• Note: 1st, 2nd, & 3rd day and Saturday delivery FEDEX & UPS is available at extra charge.