MERKUR XR4Ti
AND SCORPIO
SPECIALISTS
SINCE 1985

ORDER FORM

FAX #: (541) 544-3100 
 BILL TO:
       NAME:_________________________________________________________
   
    ADDRESS:_________________________________________________________
   
     STREET:_________________________________________________________
  
       CITY:_______________________ STATE:_____________ ZIP:_________

 HOME PHONE:_____________________BUSINESS PHONE:_____________________

BANK CARD #:________________________ EXP. DATE:__/__

We accept Visa, MasterCard, Discover and American Express.

  CAR MODEL:_______________ YEAR____ AUTOMATIC OR MANUAL 
PLEASE SPECIFY: UPS Ground
    (Circle)    UPS 3 Day
                UPS 2 Day
                UPS Overnight
                Other

SHIP TO:
   NAME:________________________________

ADDRESS:________________________________

 STREET:________________________________

   CITY:________________ STATE:_________ ZIP:_______
QTY. ORD. PART NO. DESCRIPTION PRICE EA. TOTAL
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. . . . .
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TOTAL .

FREIGHT WILL BE QUOTED AT TIME OF SHIPPING; NO PERSONAL CHECKS OR COD'S;
PLEASE INCLUDE YOUR RETURN FAX NUMBER.

ANY SPECIAL INSTRUCTIONS:____________________________________________________ __________________________________________________________________________ __________________________________________________________________________

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