The Carburetor Shop LLC
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For
those of you who are responding to an email, and placing a order by email;
PLEASE print this page, fill out the entire page and send by email. IF USING
THIS FORM, PLEASE TYPE! WE WILL NOT ACCEPT A HANDWRITTEN ORDER. IF YOU CANNOT
TYPE, PLEASE CALL INSTEAD. This page may seem too specific, but it has been
designed for our non-USA customers.
Company
name (if applicable)
___________________________________________________________
First
name or initial (required)
___________________________________________________________
Last
name (required)
_________________________________________________________________
Shipping
address – building (if applicable)
_________________________________________________
Shipping
address – street (required)
______________________________________________________
Shipping
address – city (required) _______________________________________________________
Shipping
address – state, province, prefecture, etc. (required)
__________________________________
Shipping
address – country (required)
____________________________________________________
Shipping
address – postal code (zip code in USA) (required)
__________________________________
VISA
or MasterCard number (we accept no other cards) (required)
_____________________________
Expiration
date of card (required) _______________________________________________________
Security
code (on the back of card –
required)_____________________________________________
Billing
address for the card (required if different from shipping address)
_________________________
Billing
address second line (if needed) ___________________________________________________
Daytime
telephone number (required for shipments outside the USA) ___________________________
The
item(s) you are ordering and prices quoted in the email
___________________________________
________________________________________________________________________________