ORDER FORMRIVERGATE RESTORATION PRODUCTS Ordered by: Ship to: Name __________________________ Name ____________________________ Address _______________________ Address _________________________ City __________________________ City ____________________________ State, Zip ____________________ State, Zip ______________________ Phone: ________________________ Phone: __________________________ email: ________________________ Car: Make __________ Model ______________ Year ______________ Qty. Item No.& Description Price Each TOTAL _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Method of Payment (Circle One): Merchandise Total __________ Visa MasterCard Check or Money Order Shipping ___________ Credit Card Number: Tennessee Residents ___________________________________ add 9.25% Sales Tax ________ __ / __ ______________________ Expiration Name of Issuing Bank TOTAL AMOUNT _______________ Signature _________________________ Required for Credit Card Orders |
