Telephone 732-842-4744
Order Request Form
To place an order by mail, please follow these instructions:
Telephone 732-842-4744
| Name | ________________________________________________ |
|---|---|
| Shipping Address | ________________________________________________ |
| ________________________________________________ | |
| City, State, Zip | ___________________________ _____ _________ |
| Telephone | ____ Home (_____) - _____ - _______ |
| ____ Work (_____) - _____ - _______ | |
| Payment Method | ___ Personal Check |
| ___ Money Order | |
| ___ Visa ____________________________________ Exp. Date ________ | |
| ___ MC ____________________________________ Exp. Date ________ | |
| BILLING Address | ________________________________________________ |
| ________________________________________________ | |
| City, State, Zip | ___________________________ _____ _________ |
| Item # | Year | Description | Cond. | Orig Box | Price | Quantity | Total Amount |
|---|---|---|---|---|---|---|---|
| __________ | _______ | ______________________________ | _______ | __________ | _______ | _________ | _____________ |
| __________ | _______ | ______________________________ | _______ | __________ | _______ | _________ | _____________ |
| __________ | _______ | ______________________________ | _______ | __________ | _______ | _________ | _____________ |
| __________ | _______ | ______________________________ | _______ | __________ | _______ | _________ | _____________ |
| __________ | _______ | ______________________________ | _______ | __________ | _______ | _________ | _____________ |
| __________ | _______ | ______________________________ | _______ | __________ | _______ | _________ | _____________ |
| __________ | _______ | ______________________________ | _______ | __________ | _______ | _________ | _____________ |
| __________ | _______ | ______________________________ | _______ | __________ | _______ | _________ | _____________ |
| __________ | _______ | ______________________________ | _______ | __________ | _______ | _________ | _____________ |
| Shipping & Handling Charges | * Sub-total : $ _______________________________ |
|---|---|
| $10.00 for orders under $100 | * Shipping : $ _______________________________ |
| $15.00 for orders between $100 & $300 | * Sales Tax : $ ______________________________ |
| $18.00 for orders between $300 & $600 | |
| $25.00 for orders over $600 | * Total Amount : $ ___________________________ |
Signature / Date __________________________________________________
