print-n-fax order form

Print -N-Fax Order Form

Name(as on card)___________________________________________________________________________________________________

make/year/model_____________________________________________________________________________________________

shipping address__________________________________________________________________________________________

city___________________________________________state______________postal code_______________

shipping method preferred: ground_____ 3 day____ 2 day____ overnight_____UPS/FedEx____Int'l______

phone#___________________________________________ fax________________________________________________

e mail address______________________________________________________________________________(required field)

part # description quantity _____________________________________________________________________________________________

_____________________________________________________________________________________________

credit card#_________________________________________expiration__________ CVV #________

billing address_____________________________________________________________________________

fax receipt _____ eMail Receipt_____ send me a PayPal Invoice_______

secure on line orders with your major credit card or check PayPal payments to: coldduc@pcsdaytona.com

toll free fax to: 866.848.7899 386.492.8101/ 386.253.2586

PCS Daytona 1842 Segrave Unit E South Daytona Fl 32119