Contact:
____________________________________ Company
: ______________________________________
Billing Address:_______________________________________________________________________________
(City)
(State)
(Zip Code)
Shipping Addess:_______________________________________________________________________________
(City)
(State)
(Zip Code)
Phone: (
) -
Fax: ( )
-
E-mail:
@
Make:
_ Model:
Year:
Problem /Complaint
with your Supercharger:
Part Number:__________________(From Catalog/Internet
Pages)
Shipping
Options:
(Check Selection)
UPS Ground:
UPS Blue:
(Two Day)
UPS Red:
(Overnight)
(Usually 2 - 4 days Approx $30 - $50.) (2 Day in U.S.
- Approx. $60 - $100) (1 Day in U.S. - Approx. $100 -
$150.00)
Payment Options :
Credit Card #:
- -
-
Ex. Date :
/
C.O.D. Certified:
Company/Personal Check
Mailed: ( Ship
once payment is received)
Bill Account:
(Dealers/Distributors Only) Purchase Order #:
Fax:# / Mailing Address