>>click to return to website<< PRINT THIS PAGE! ORDER FORM Mail to: Mr Darnell Ross, 1601 Bramwell Rd. Richmond, VA 23225 Fax to: 1-804-276-3504 (24hours) If paying via PayPal or ProPay: send your money to: mrdarnellross@aol.com Name or Business name_____________________________________________________________________ Dealer #_____________ Email:_______________________Phone#____________________________
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Shipping & Payment Information Fax to: 1-804-276-3504 (24hours)
Order being shipped to: Is this order being dropped shipped? [ ]YES [ ]NO PAYMENT TYPE: NAME_____________________________________________________ [ ]CHECK [ ]CREDIT CARD ADDRESS __________________________________________________ [ ]MONEY ORDER [ ]PAYPAL CITY______________________________________________________ CHOOSE CREDIT CARD: STATE___________________________ ZIP______________________ [ ]VISA [ ]MASTER CARD [ ]DISCOVER [ ]AMEX CARD No:_______________________________________________ Exp. Date:________________________________________________ Cardholder Signature: X_____________________________________
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