PURCHASE ORDER FORM

PLEASE COMPLETE THE PURCHASE ORDER FORM BELOW COMPLETELY FILLED OUT, SIGNED AND DATED ALONG WITH YOUR PAYMENT.

 IF YOU ARE WIRE TRANSFERRING YOUR PAYMENT OR MAKING YOUR PAYMENT BY CASHIERS CHECK, MONEY ORDER OR CERTIFIED CHECK (no personal checks) THEN PLEASE PRINT OUT THIS FORM AND EITHER FAX TO 860-540-1333 OR MAIL IT TO P.O. Box 2532 New Britain ,CT 06050 USA, ALONG WITH YOUR PAYMENT.

YOU MAY ALSO CALL 860-612-0466  for Additional Questions!

First Name:
Last Name:
Email:
(double check spelling)
Company:
 

Address:
(please be sure to enter a physical mailing address)
City:
State:
Zip:
Country:
Phone:
Fax:
 
Additional Comments / Questions:

 

Product Order List
PART NUMBER DESCRIPTION PRICE QTY. AMOUNT
  SUBTOTAL
    SALES TAX
Connecticut 6.00%

 
    SHIPPING CHARGES CHECK WITH US 
    TOTAL 

                            Payment Information

Payment Type: Cashiers Check Money Order Certified Check
Bank Wire Transfer Pay Pal
Western Union Quick Collect (domestic)
Western Union Quick Pay (foreign)
Check or Document Number:  
Bank Name:
I (print name) , have read and understood EDOZONE's "Terms & Conditions of Sale" and agree to abide by them. I have placed the above purchase order and authorize EDOZONE. to accept the payment that I have made for the above order and ship the listed items to the address provided. 
CUSTOMER SIGNATURE       DATE 
                      Vehicle Information
YEAR MAKE MODEL BODY