To Order by Fax or Mail
Complete and fax this form to Pending
Or complete and mail, fax or e-mail it to admin@gasalleystreetrods.
Step 1 - Contact Information

Billing Address:
Name_______________________________
Street_______________________________
City_________________________________
State________________________________
Zip/Postal Code______________________
Country_____________________________
Daytime Phone #_____________________
E-mail Address_______________________
Ship To Address, if different (for UPS shipping, a street address is required - UPS will
not deliver to PO boxes)
Name_______________________________
Street_______________________________
City_________________________________
State_______________________________
Zip/Postal Code_______________________
Country_____________________________

Step 2 - Products
Quantity         Item #         Description        Price Each        Item Total
   
   
   
   
   
   
   
   
   
   
   
   
   
Subtotal         


Step 3- Shipping, Tax, and Payment
Product Subtotal from above _____________________
Shipping Charges (See shipping chart here) _________________
Hawaii, Alaska, and Foreign Orders: Please call 913-244-0112 for a shipping quote.
Orders shipping to Kansas addresses add 6.75% Sales Tax ______________
Total Payment ______________
Payment Method
Visa___ MasterCard___ Discover___  Check or Money Order Enclosed________
Credit Card #________ - __________ - __________ - ___________
Expiration Date__________ / __________

Signature___________________________________________________________

Special Shipping Items (e.g. Completely Assembled Carburetor Setups) require extra
shipping charges.

Orders containing hazardous items can only be shipped via UPS Ground (to the Lower
48 United States)
Carbs - Quality re-manufactured / rebuilt carbs and
setups.  Specializing in Stromberg 97 / 48 / 81's
Phone: 913-244-0112
email:
rickshelton@gasalleystreetrods.
com