Car Connection Ohio

ORDER FORM:

Thank you for your order. NO COD's

Please complete this form, & fax to 513-425-7281

Card holder name:____________________________________________________

Address:___________________________________________________________

City:_______________________ State:___________________Zip:_____________

Phone:_____________________________    Fax:__________________________

Email:_____________________________________________________________

Visa / Mastercard / Discover      Card #:___________________________________

Expiration Date: _____________________ Sec. code (from back of card): ______________

ALL QUOTES ARE QUOTED AS SHIPPED TO A BUSINESS.

RESIDENTIAL DELIVERY WILL BE ADDITIONAL.

Part Requested:_______________________________________________________

Year:________________ Make / Model:____________________________________

Part type:____________________________________________________________

Side (if needed):______________________

Quoted for $____________ Shipping $____________________(if needed)

Shipping address (if different from billing address)

Business Name:_______________________________________________________

Attn. to :____________________________

Address:_____________________________________________________________

City:________________________State:_____________________Zip:____________

I authorize Car Connection Ohio to charge my credit card.

Signature ________________________________

Date: __________________