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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