Patkes Part Request Form
Business Name
Attention
Address
City / State / Zip
Phone
Fax
Email Address
Visa
Mastercard
#
Expires
This is not a secure server for sending credit card information. Please
fax this order form if you would like to purchase. Fax: 713-734-1633
SHIP TO
: (if different than mailing address)
Business Name
Attention
Address
City / State / Zip
PART REQUESTED
:
Year
Make / Model
Side Needed
Option Needed
Price Quoted $
Freight Quoted $
ALL QUOTES ARE FOR BUSINESS DELIVERY!
RESIDENTIAL DELIVERY WILL BE ADDITIONAL!
UPS ground $5.00, Trucking $75.00
Warranty Quoted
Signature x_____________________________________ Date
A signature is required for the processing of this Order Form
* Required
Copyright ©2001 Patkes. All rights reserved.
