** - Headings with two "*" are for required information. Please print out, complete, and E mail form to: dualbrake@bell.net
** Shipping Address ( If you have a different Billing Address; please fill out the table at the end of this form. )
** Name:.
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Company Name.
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** Address.
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** City and State (or Province) .
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** Zip Code / Postal Code.
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Contact Information:
** Phone
Number:
. Alternate Phone Number: .
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E-mail Address: Recommended: This way we can send you shipping conformation. .
Payment Information: "Brouwer Manufacturing Ltd." is the name that will appear on your credit card statement. We accept Visa or Mastercard
** Expiry Date
(month / year ):
/
** Card Number: .
** 3 digit CVV code on back: . ** Holder Name
(as it appears on card):
.
Your Purchase order number; if applicable:.
.
Shipping and Handling (as per Buy Now web page):
** Speed ( please circle one of four ):
UPS Expedited, UPS Standard
Express Post, Standard Post
$C$
Shipping and Handling Cost:
.CnD
USD
$C$ - Circle the appropriate currency: USD for United States Dollar or CnD for Canadian Dollar.
What would you like us to ship?
** Quantity Item # Item Name Price Each $C$ Price Total
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Billing Address
Name:.
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Company Name.
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Address.
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City and State (or Province) .
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Zip Code / Postal Code.
.