ORDER FORM

WEB ORDERS: Enter all information in Sections 1 - 4, and then click on the SEND button. FAX ORDERS: Enter all information in Sections 1 - 5 (or print this form out and enter your information) and FAX to (817) 244-3647. To verify receipt, entry and/or acceptance, call (817) 244-3647. "RELEASE NUMBER ORDERS" UNDER ANNUAL CONTRACTS AND BLANKET ORDERS: Enter AC# or BO#, Release#, and Date in section 5, and then FAX to (817) 244-3647, or press SEND button. To verify receipt, entry and/or acceptance, call (817) 244-3647.


Section 1 - Items Ordered:
Section 2 - Sold To:
Section 3 - Drop Ship To:
Section 4 - Vehicle Information:
Section 5 - Payment Method:
Section 6 - Authorized Signature, Title, Date:

Congratulations on your decision to order hardware,software, or services from Power & Acceleration Center.

 
2. CUSTOMER NAME / SOLD TO:
 
Company:
Contact's Name:
Address:
City:
State:
Zip:
A/C & Phone:
A/C & Fax:
Website:
Email:
 
3. DROP SHIP TO:
 
Company or Name:
Address:
City:
State:
Zip:
Attention:
 
4. VEHICLE INFORMATION:
 
Year, Make, Model:
Engine
(Gas/Diesel & cubic inch/liters):
Stock Computer Code:
 
5. PAYMENT METHOD:
 
Payment Method: Purchase Order  MasterCard Visa Amex
Purchase Order Number:
Tax Exempt Number:
(Hard Copy Required)
Credit Card Type:
"EXACT" Card Billing Name:
"EXACT" Card Billing Zip:
"EXACT" Card Number:
"EXACT" Card Expiration Date:
Telephone Number:
 
6. Authorized Signature, Title, Date (Required for FAX, PO and hard copy orders only):
 
Authorized Agent's Signiture:
Agent's Title:
Date:
 

NOTE: If paying by credit card please give us the number and expiration date. If you want to make the transaction by telephone you must provide your area code and telephone number in the form above.

      

BACK TO START.

CLICK HERE if you have a question about order procedures?