| 1) PRINT FORM (Use BACK button to RETURN) | PHONE: DAY:________________________________ |
| 2) FILL IN ORDER - PLEASE PRINT CLEARLY | EVENING:____________________________________ |
3) FAX ORDER TO: 770-594-2245 |
| SHIP TO: IF DIFFERENT FROM BILL TO | |||
| CREDIT CARD BILL TO: | BUSINESS NAME:_______________________________ | ||
| NAME:_____________________________________ | YOUR NAME:________________________________ | ||
| STREET:_____________________________________ | STREET:_____________________________________ | ||
| APT/BLDG:_____________________________________ | APT/BLDG:_____________________________________ | ||
| CITY:_____________________________________ | CITY:_____________________________________ | ||
| STATE:______________ | ZIP:______________ | STATE:______________ | ZIP:______________ |
| QTY | PRICE EA. | TOTAL | |
| _______ | LITTLE BIG HORN for TWIN CAM | 105.00 | ________ |
| _______ | LITTLE BIG HORN for EVOLUTION | 105.00 | ________ |
| _______ | LITTLE BIG HORN for JAPANESE | 105.00 | ________ |
| _______ | LITTLE BIG HORN for OTHER AMERICAN | 105.00 | ________ |
| _______ | LITTLE BIG HORN for EURO | 105.00 | ________ |
| _______ | BIG HORN for TWIN CAM | 150.00 | ________ |
| _______ | BIG HORN for EVOLUTION | 150.00 | ________ |
| _______ | BIG HORN for JAPANESE | 150.00 | ________ |
| _______ | BIG HORN for OTHER AMERICAN | 150.00 | ________ |
| _______ | Dual for Ultra with fairing lowers | 170.00 | ________ |
| _______ | DYNAMIC DUO for Evo | 150.00 | ________ |
| _______ | DYNAMIC DUO for TC88 | 150.00 | ________ |
| _______ | NOSECONE DIRT GUARD | 10.00 | ________ |
| _______ | GC-01 GORILLA CABLES | 39.00 | ________ |
| _______ | GC-02 | 57.00 | ________ |
| _______ | GC-03 | 39.00 | ________ |
| _______ | GC-04 | 57.00 | ________ |
| _______ | GC-05 | 57.00 | ________ |
| _______ | GC-06 | 57.00 | ________ |
| _______ | GC-07 | 39.00 | ________ |
| _______ | GC-08 | 57.00 | ________ |
| _______ | GC-09 | 39.00 | ________ |
| _______ | GC-10 | 39.00 | ________ |
| GA RESIDENTS ADD 7% SALES TAX | _______ | ||
| SHIPPING/HANDLING - SEE CHART BELOW | _______ | ||
| TOTAL | _______ | ||
FOR EACH ADDITIONAL HORN ADD $4.00 PER UNIT UPS NEXT DAY ADD AN ADDITIONAL $45.00 ALASKA AND HAWAII ADD AN ADDITIONAL $25.00 | MAKE:_______________________ MODEL:______________________ YEAR:_______________________ |
| VISA | _____ | AMERICAN EXPRESS | _____ |
| MASTERCARD | _____ | DISCOVER | _____ |
| CREDIT CARD NUMBER: | ________________________________________ |
| EXPIRATION DATE: | ________________3 or 4 digit security code________ |
SIGNATURE: PRICES GOOD IN US ONLY | ________________________________________ |
| Shipping/Handling not refundable, return authorization required. | |