Adirondack Dodge Parts

Adirondack Dodge Parts Order Form(print then mail or fax)
Box 99
Prospect, N.Y. 13435
Tech/Info(315)896-2572
Fax (315)896-2199
Orders Only: 1-800-932-8020
(Http://www.adirondackdodgeparts.com)
Purchaser's (Bill To) Address Ship To: (If different)

Cust. No:___________________________
Name:_____________________________
Address:___________________________
City/State:__________________________
Zip:_________Phone:_________________

Name:________________________________
Address:______________________________
City/State:_____________________________
Zip:_________Phone:____________________

QTY	Description	Unit Price	Total Price
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
____	_________________________________________________________	_________	__________
		Sub Total	__________
	N.Y. Residents add 9% Sales Tax	N.Y. Tax	__________
	Haz-Mat Fee $17.00 (for gallons of paint)	HM Fee	__________
	UPS Shipping & Handling	Shipping	__________
		TOTAL	__________

()Personal Check ()Money Order ()COD (Cash Only)

_____________________________________
Customer Signature

_____________________________________
Date

Credit Card Information:. • VISA    • MasterCard (circle one)
Account Number:______________________
3 Digit Card Code (On Back) ________
Expiration Date:___/___/___ Phone:______________
Card Holders Signature:
______________________________________________ Please Print Name as appears on card:          _____________________________________________

Merchandise is not returnable after 30 days. No returns on special order parts. All UPS orders should include a 10% estimated charge or call for charges.
We hold personal and company checks until bank clearance. Prices are subject to change with out notice. Please call for current prices before ordering. Call for overseas pricing.