Rowley Corvette Supply           * * * * * FAX ORDER FORM  * * * * *

 TELEPHONE:   978-948-7730   FAX:  (978) 948-3759
 357 Main Street /  Rowley MA  01969  U.S.A.  

 Please print out this form & fax it to: (978) 948-3759 
  
   
 DATE:_________________
  
   
 Name: _____________________________________________________________ 
  
 Company (optional): _______________________________________________ 
  
 Address:___________________________________________________________ 
  
 City/State/Zip: ___________________________________________________ 
  
 Corvette info (yr, model, engine, colors): ________________________ 
  
 Quantity       Part #         Brief Description: 
  
 ___________________________________________________________________ 
  
 ___________________________________________________________________ 
  
 ___________________________________________________________________ 
  
 ___________________________________________________________________ 
  
 ___________________________________________________________________ 
  
 ___________________________________________________________________ 
  
 ___________________________________________________________________ 
  
 ___________________________________________________________________ 
  

 Your Email Address: ______________________@________________________ 
  
 Contact Phone: ____________________________________________________ 
  
 FAX (optional): ___________________________________________________ 
  
            ******** CREDIT CARD INFORMATION   ******** 

 Credit Card #:_____________________________________________________ 
                          (Visa or Master Card) 
  
 Exp. Date: __________  Name on Card: ______________________________ 
  
 Credit Card BILLING address if different from shipping address: 

____________________________________________________________________ 
  
   
 Signature: X____________________________________ 
  
 I authorize Rowley Corvette Supply, Inc. to charge my credit card 
 for the amount circled above.  I understand that my order  
 will be processed within 48 business hours. 
  
   
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 Problems or questions? Please call us at (978) 948-7733  
 10:00am to 4:00pm eastern std. time  
  
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