To order, print out this form, fill in all requested information.

	Bill to:	Ship to:
Name
Street Address
City
State/Zip
Phone Number
Fax Number
E-mail address

	Qty	Item	Price Each	Total (Qty x Price)
1
2
3
4
Shipping (circle one): UPS Ground (see below) UPS 3 Day Air (add $8.50 to Ground) UPS 2 Day Air (add $16.50 to Ground) UPS Next Day Air (add $29.50 to Ground) NOTE: All CJ steering columns are shipped UPS Ground at cost of $21.50 Method of Payment (circle one): Visa Mastercard Money Order C.O.D. (additional $7.50 fee)			Subtotal
			Shipping (see left)
			Add $2.50 handling
			Add $7.50 if COD payment
			If PA resident, add 6% sales tax
			Total Due
If paying by credit card, please supply: credit card # ___________________________ expiration date ___________

Shipping Charges
Order Subtotal	$0 - $24.99	$25 - $49.99	$50 - $99.99	$100 - $199.99	over $200
UPS Ground Shipping Cost	$6.50	$9.50	$11.50	$13.50	$16.00

I hereby authorize the purchase of the above item(s) and confirm that I accept the terms of the return policy and warranty:

signature _____________________________________ date __________________

We cannot fill the order if any part of this order form is incomplete. Prices are subject to change. If you have any questions while filling in this order form, please call (610) 754-0720 weekdays between 8:30 am and 5:30 pm EST to place the order directly over the phone.

Please mail completed form(s) to: Centech Wiring, 2190 Colflesh Rd., Perkiomenville, PA 18074 or fax to: (610) 754-0745