Sold To: Ship To: (If different from sold to) Name: __________________________ Name: _______________________________ Address: _______________________ Address: ____________________________ City: __________________________ City: _______________________________ State: _____ ZIP: ______________ State: _____ ZIP: ___________________ Eve Phone: (_____) _____-_______ Day Phone: (_____) _____-____________ These parts are for: Make___________, Model________, Year______________ Hardtop, Post coupe, or Convertible? ___________________________________ My T-Shirt size is ____________________ My E-mail Address is:__________________
| Qty | Part Number | Description: | Price Each | Total |
I have enclosed:$_____.___ by: Please Check type of payment below ___ Personal Check: personal checks require ten days for clearance. ___ Visa: MasterCard, Visa, or Discover Card: We will ship immediately. ___ MasterCard: ___ Discover: Requested card information. Expiration Date: ____/____ Card Number:_____________________
Signature: ______________________
Subtotal: _____.___
VIP Insurance-all orders: $2.00
(Shipping cost will be billed to your charge card) Shipping Charges: _____.___
We may hold Tax (if Kansas Resident.) 5.25%: _____.___
Grand Total: _____.___
Mail or fax this order form to: FAX: (913)851-7986
Brothers Automotive Phone:(913)851-7977
7275 W. 162nd St. Suite 103 TOLL FREE:(800)442-PART
Stilwell, Kansas 66085 Business Hours : 8:00 AM - 5:00 PM
Central Standard time
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