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Please print and complete the form below.
Your Name:
Name:_______________________________
Address:_____________________________________
City State Zip:_________________________________
Country:_____________________________________
Phone #:_____________________________
QTY Item # Description
Item Price Total Items
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________
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Sub Total:
_______________
-Discount: 5% off orders if over $300.00 _______________
Quoted shipping and handling _______________
Grand Total:
_______________
Payment Method (circle one) MONEY ORDER,
Visa, Mastercard, Discover, American Express
Credit Card Billing Address: (only if using credit card)
Name:_________________________________
Address:_____________________________________
City State Zip:________________________________
Credit Card
Account Number:______________________________
Exp Date: ______________
Please send
completed form and payments "unless credit card" to:
PATS SMALL ENGINE PLUS
680 EAST DUAL BLVD
ISANTI, MN 55040
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