Hot Rod Depot - Fax/Mail Order Sheet

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Ship To Address: (Cannot be a PO Box)

First & Last Name    :
Street Address       :
City, State & Zip    :
Day Time Telephone # :
Email Address        :
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Billing Address: (Required! Must match billing address on credit card)

Name                 :
Address              :
City, State & Zip    :
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Method of Pre-Payment: (No COD's)

Card Type            :
Card Number          :
Expiration Date      :
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Year, Make & Model:(Please enter all info relative to your order)



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Description (Please Indicate quantity, part #'s, and prices)











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Comments / Special Instructions



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I hereby authorize Hot Rod Depot to charge my credit card account for the parts
listed above and including shipping & handling fees incurred in the transportation
of the merchandise requested above.   Refunds are limited to the purchase price of
the goods sold.  Shipping charges are non-refundable.

Signature X______________________________

Print Name Here__________________________

Date ___________________


Hot Rod Depot 3665 E Patrick Lane #2 Las Vegas, NV 89120
Phone 702-262-0077 Fax 702-262-0099