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Order & Payment Form
SALESMAN INFORMATION
Your Sales Person*
YOUR INFORMATION
First Name:*
Last Name:*
Business / Company
Your Address*
Your Phone Number*
Your Email*
BILLING INFORMATION
First Name*Same name as on your card
Middle Initial
Last Name*
Address 1*
Address 2
City:*
Postal Code:*
State:*
Phone:*
CREDIT CARD INFORMATION
Name On Card*
Card Number:*No dashes or spaces please
Card Brand:*
CID #*
Expiration Year:*From your card
Expiration Month:*From your card
Amount To Be Billed*
SHIPPING INFORMATION
Please Note: Starting in 2013, we are no longer able to ship to any other address, other than the billing address on your credit card. We apologize in advance, for any inconvenience.
You must also fax and or email a copy of your photo ID, and the credit card we are processing. this step is mandatory. Do not proceed with this form, if you are not able to do so. Contact your sales representative, for any questions or concerns.
First Name:*
Middle Initial:
Last Name:*
Address Line 1:*
Address Line 2:
City:*
State:*
Postal Code:*
PART INFORMATION
Parts You Are Ordering:*
Edition
Car Make*
Car Model*
Attatch A Picture Of Part (optional) 
PLEASE READ BEFORE SENDING
All returned parts are subject to a 25% restocking fee: (unless defective)*

Shipping charges are not refundable*

All parts have a 30day warranty unless otherwise stated*

Questions, Comments, Special Instructions:
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