American Performance Order Form
(PRINT, THEN FAX or MAIL) (HELLOFAX.COM TO SCAN & FAX)
NAME:__________________________________________________________ DATE:
ADDRESS:___________________________________________________________
ZIP CODE: _______________
CITY: _____________________________________ STATE:_________________
COUNTRY:_____________________
PHONE #:(__ __ __) __ __ __-__ __ __ __
CIRCLE 1: WORK/CELL/FOREIGN: __ __ __ __ __ __ __ __ __ __ __ __ __ __
Make/Model:_______________________________ Year: 19 ____ Engine:_______
DOOR-TAG: Model: ________-___
| Part #: | Description: | Qty. | Price: | Total | |
| 01)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 02)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 03)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 04)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 05)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 06)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 07)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 08)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 09)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 10)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 11)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 12)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 13)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 14)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 15)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 16)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 17)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| 18)_____ - ________ | _______________________________________ | ____ | $_______ | $_______ | |
| SUB-TOTAL: | $______ | ||||
| SHIPPING: ESTIMATED (Minimum of $21.00 or 18% whichever is more) | $______ | ||||
| ADDITIONAL SHIPPING FOR HEAVY~OVERSIZE~FOREIGN to be determined upon shipment: | $_TBD_ | ||||
|
All Major Credit Cards and PayPal are Accepted __ __ __ __~__ __ __ __~__ __ __ __~__ __ __ __*__ __ __ |
Total: | $______ | |||
*IMPORTANT: 3 or 4 DIGIT SECURITY CODE: _________
EXPIRATION DATE: MONTH:__ __ YEAR:__ __
Name on Card _________________________________
Signature: ___________________________________
FOREIGN ORDERS: E-MAIL ADDRESS REQUIRED:
______________________________@_______________
NOTE: If billing address is different from shipping, please print below.
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_____________________________ American Performance Products 675 South Industry Road Cocoa, FL 32926 321-632-8299 321-632-5119(Fax)
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