| Date________ Name__________________
Phone_____________ E-mail___________________ |
| Billing Address St________________________________
St 2______________________________
City______________________________
State_____________ Zip_____________ |
Shipping Address
St________________________________ St 2______________________________
City______________________________
State_____________ Zip_____________
|
| Payment Info (check one): Visa___
MC___ Dis___ Amex___ Check___ Money Order___ |
| Number______________________
Exp_______ V-Code_____ Signature___________________ |
| Order Information |
| Front Seat Qty____ |
Color_____________ |
Price________ |
Total_________ |
| Middle Seat Qty____ |
Color_____________ |
Price________ |
Total_________ |
| Rear Bench Qty____ |
Color_____________ |
Price________ |
Total_________ |
| Headrest Qty____ |
Color_____________ |
Price________ |
Total_________ |
| Sub Total |
Total_________ |
| |
|
| Shipping, Cont. US UPS Ground (1 cover $14.99, 2
covers $18.99) |
Ship_________ |
| Tax- California (please add 8.25% state tax for
California orders) |
Tax__________ |
| Grand Total |
Total_________ |
| Special
Requests?_______________________________________________________________ |