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REPLACEMENT
PARTS
ORDER FORM
Stainless Steel Brakes Corporation
11470 Main Road • Clarence, NY 14031
Ph: 716-759-8666 Fx: 716-759-8688
ssbrakes.com • [email protected]
DATE: __________________________
CUSTOMER #
ORDERED BY:
SHIP TO:
NAME: _______________________________
NAME: _______________________________
COMPANY: ____________________________
COMPANY: ____________________________
STREET: ______________________________
STREET: ______________________________
CITY: ___________ ST: ____ ZIP: _________
CITY: ___________ ST: ____ ZIP: _________
DAY PHONE: ___________________________
DAY PHONE: ___________________________
FAX: _________________________________
FAX: _________________________________
E-MAIL: ______________________________
E-MAIL: ______________________________
VEHICLE INFORMATION:
TYPE OF DRIVING:
TYPE
OF
(from receipt): ____________
AUTOMOBILE: _________________________ __ STREET
YEAR ______ ENGINE: __ 4
CYL.
__ 6
CYL.
__ 8
CYL.
__ RACING
__ STREET & SLALOM
ORDER INFORMATION:
QUANTITY
PART #
DESCRIPTION
UNIT PRICE
ORDER
__ VISA
AMOUNT
Total Merchandise
METHOD OF PAYMENT:
__ CHECK/MONEY
__ STREET MODIFIED
__ MASTERCARD __ DISCOVER
__ AMEX
NY Residents Sales Tax
Ins. (add $0.35 per $100.00)
CREDIT CARD #: _____________________________ EXP: _____________
SIGNATURE: ___________________________________________________
UPS Shipping
(please call)
TOTAL
Price subject to change without notice. Not responsible for typographical errors.
NOTE: Name, address & telephone number must be printed on checks. Driver’s License number
required for personal checks.
FREE FREIGHT
IF ORDERED WITHIN 30 DAYS OF INITIAL ORDER
MAIL OR FAX YOUR ORDER!
Solutions Guide Revision 5
6
716-759-8666 • [email protected]