ORDER FORM

Name:_________________________________

Address:_______________________________

City:__________________________________

State/Prov:_____________________________

ZIP/Postal Code:________________________

Phone: ________________________________

Car year & body type_____________________

[ ]with A/C [ ]Slant 6 K-member [ ]V-8 K-member
[ ]Automatic               [ ]Power Steering  [ ]Manual Steering

Check engine to be installed:[ ]273/318 [ ]340/360 [ ]361/383/400
                                                  [ ]440/413/420 Wedge [ ]426 HEMI

Enclosed is a: _____Check _____ Money Order

Charge my credit card:__Visa __ MC __Amex __ Discover

Card #_____________________________ Expires____________

Cardholder Name ______________________________________

Signature ____________________________________________

(WA State residents ONLY, 9.8% on Product & S&H Total)

Quantity

Description

Unit Price

Total

       
       
       
       
       

Order by Phone: 1-206-364-7151  
Or by FAX: 1-206-440-5464  
Visa
Mastercard
American Express
Discover

Sub Total

 

Shipping

 

Sales Tax

 

Total

Make check or MO payable to:
Schumacher Creative Services — 2025 NE 123rd, Seattle, WA 98125