Brothers Automotive Order Form

Call 913-764-0403 or 1-800-442-PART (7278) TO ORDER

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.
Card Number:_____________________ Expiration Date: ____/____ 3 Digit CVV2 code from rear of card:_____________________ 

Signature: ______________________
                                                             Subtotal: _____.___
		                             VIP Insurance-all orders:    $2.00
(Shipping cost will be billed to your charge card)   Shipping Charges: _____.___
                              Sales Tax (Kansas Residents Only!) 7.5%: _____.___  
                                                          Grand Total: _____.___
Mail or fax this order form to: FAX: (913)764-0583
Brothers Automotive  Products   Phone:(913)764-0403 
19925A W 161st St               TOLL FREE:(800)442-PART(7278)
Olathe, Kansas 66062          M-F 8:00 AM - 6:00 PM CST

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