5614 S.W. 25th Street, Hollywood, FL 33023, Ph: 954-966-7329, Fax: 954-966-3584

Fax Order Form

Directions: (1) Type info into blank fields, (2) Print it out, (3) Fax it.
BILL TO: (Check Name or Company for Billing Purposes)    PO# 
Name:               Company:
Address: 
City:   State:   Zip: Country:
Phone:   Fax:
Charge Card:  (check one)      Visa            MasterCard           Amex         Discover
Card Number:   Expiration Date:
 Cell:              Email: 
SHIP TO:  (if different from billing address)       AC Tail # or Boat Name:    
Name:    Company:
Address:
City:   State:   Zip: Country:
Phone:   Fax:    Cell: 

 Qty.

Part Number

Description

Price (Check One)

   Buy    Rent   Service
 

 
 
 

Total:

  
Note:  Rental Charge begins on the day item(s) leave our facility through the date the items arrive back to our facility regardless of     what time they are picked up or returned.  Rentals are a 2-Day minimum.  Rental cancellations are due at least 48 hours in advance.  
FOR PURCHASE:  Specify if needed by a particular trip date:
FOR SERVICE:  Regular T.A. (Approx. 2-3 weeks).  Expedite 25% Additional (Approx. 2-3 days)
           Date needed by:
FOR RENTAL:  Date Needed:         *Approx. Return Date: 
DELIVERY:  UPS Ground     Next Day     Second Day   Third Day     Customer Pickup
Special Shipping Instructions:        
Signature:__________________________________                  Date:
Note:  For shipping back rentals or service work, call our Rep., Jeff Heidenreich at Freightquote.com.           Ph: 800-323-5441 x1732, Fax:  913-319-0635, or Email:  jheidenreich@freightquote.com for best price.