LAND AND WHEELS ORDER FORM (required fields)
U.S Sales Only
 
  BILL TO:   SHIP TO: (If different from Bill To:)
   
Customer Number Customer Number
Purchase Order    
Facility Facility
Your  Name Your  Name
Address Address
City State, Zip:
City, State, Zip
Phone: Phone
Fax: Fax
Email: Email
       

Items To Order

Qty Item Number Color Item Name Brand Serial Number Price Amount

Your Comments:

Handling Charge on orders under$50.00         Add $3.50  

                                        +UPS or Fedx         

*

* Shipping charge is determined at time of packing

Total Cost 

Credit Card Info

Visa

Master Card

cvv code

Exp Date

Finalize Order