Sales Person: ____________________

SHIPPING ORDER - FIRST DATE CAR AVAILABLE FOR TRANSPORT: ____________________

BILLING INFORMATION

Name: __________________________________ Phone: ____________________ Email: ________________________
Billing Address: ______________________________________________ City/State/Zip:
____________________ / _________ / _____

PICK UP VEHICLE FROM

Name: _________________________ Home Phone: ____________________ Business Phone: ____________________ Cell Phone: ________________________
Address: ______________________________________________ City/State/Zip:
____________________ / _________ / _____

DELIVER VEHICLE TO

Name: _________________________ Home Phone: ____________________ Business Phone: ____________________ Cell Phone: ________________________
Address: ______________________________________________ City/State/Zip:
____________________ / _________ / _____

VEHICLE DESCRIPTION

Registered Owner/Leasee: _________________________ Car Make/Model/Year: ____________________ License Plate/State: ____________________ Color: ________________________
VIN:
________________________
ADDITIONAL INFORMATION AND PHONE NUMBERS FOR PICKUP AND DELIVERY:



PLEASE CHECK

Compact Car
Sedan
Truck
SUV		 Van
Mobile Home
Motorcycle
 		 Trailer
Boat
Minivan

IS VEHICLE OPERABLE? YES NO

Payment Amount:




 Check Visa MC AMEX Disc.
Full Payment with order or
$200 deposit, Balance _________ cash or cashiers check on delivery.

Full payment by credit card.

Card No.: _________________________ Exp. Date: __________
Card Holder: _______________________
By signing below, I authorize charges on my credit card and agree to all terms and conditions.

Owner's or Shipper's Signature: _______________________________________
Print Name and Date: _______________________________________

How did you hear about our service? _________________________

Price valid for 30 days. A $25 charge will be assessed for returned checks.
INSTRUCTIONS: COMPLETE THE FORM ON THIS SCREEN, CLICK 'PRINT ORDER FORM', SIGN AND FAX TO: 818-244-5585.