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Billing Address
Name: _______________________________________ Date: ___/___/_____
Address: ______________________________________________________
City: ________________________ State: ____________ ZIP: ____________
Home Phone: (____)______________ Work Phone: (____)_______________
E-mail Address: _______________________ Your personal zip code: _______
Shipping Address (if different from Billing Address)
Name: ___________________________________________
Address: ______________________________________________________
City: ______________________ State: ______________ ZIP: ___________
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Product (or Part # if listed) |
Description |
Price |
Quantity |
Extended |
| 1. |
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| 2. |
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Subtotal:
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$__________ |
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Sales Tax (For Calif. residence please add 9.25%
sales tax):
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$__________ |
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Shipping & Handling (please use shipping cost
table on web site):
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$__________ |
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Grand Total:
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$__________ |
Mail with the correct payment by personalized
check, money order or credit card information.
All checks and money orders must by in U.S. Dollars payable on a U.S.
bank.
Mail To:
Walt's Cycle
116 Carroll Street
Sunnyvale, CA 94086 |
Fax To: (408) 739-2837
24 Hours / 7 Days A Week
Phone To: (866) WALTS-55
Mon - Sat: 9:30am - 5:00pm PT
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Credit Card Information
Visa: _____ Mastercard: _____ Discover: _____
Card #: __________________________________ Expiration Date: ____/____
Name On Card (Please Print): _______________________________________
I hereby authorize Walt's Cycle to debit the above identified credit
card
in the amount of $______ in U.S. Dollars.
Signature: ______________________________ Date: ____/____/_____
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