FAX ORDER FORM - Dealer / Retail
SHIP TO:
Name
 _______________________________
Address
 _______________________________
_______________________________
_______________________________
Day Phone
_______________________________
Eve Phone
 _______________________________
Fax No.
 _______________________________
Email
_______________________________


                        912-A Pancho Road
                        Camarillo, CA 93012
USA
                1-805-388-8803
PART #
QTY
COLOR
DESCRIPTION
YEAR
PRICE
TOTAL
             
             
             
             
             
             
Credit Card Information

Name on Credit Card________________________
SUBTOTAL  
Sales Tax
8.25% CALIF
 
residents only
 
SHIPPING COSTS  
TOTAL  
__Visa__MasterCard Number____________________________Exp Date___________

V- CODE (3 numbers on back of card): _________

The issuer of the card identified on this item is authorized to pay the amount shown as TOTAL. I promise to pay such TOTAL together with any other charges due thereon subject to and in accordance with applicable law and the agreement governing the use of such card.
Signature X_____________________________________Date:_________

PLEASE FAX THIS ORDER FORM TO ZERO GRAVITY AT 1-805-388-8285