Order Information:

(You can print this out and mail or fax it in with your order)

Name:________________________________________	Yr:______ Make:________________
Address:______________________________________	Model:_________________________
City:_____________________ State:____ Zip:________	Engine:__________ Trans:_______________
Work Ph.:______________ Home Ph.:______________	Options:______________________________
E-Mail Address:_______________________________	Modifications:___________________________
	______________________________________

Shipping Address- If different than above
(COD orders must be to an address where someone is there to accept the package anytime in the day)

Name:________________________________________________________

Address:______________________________________________________

City:___________________________ State:___________ Zip:___________

Ship Via:___________ Order No:____________(We Provide) Prepaid:___ COD:___ Date:    /    /

Quantity	Part Number	Description	Price

Send To:	Or Fax To:	Parts Subtotal:	_______________
Mantapart	330-549-0410	Tax (OH only):	_______________
PO Box 2206		Freight/COD:	_______________
New Springfield, OH		Core Charge:	_______________
44443		Balance Due:	_______________