bikeparts.com FAX/MAIL ORDER FORM
Please print this form and either:

Customer Information:

NAME: HOME PHONE:
COMPANY: WORK PHONE:
ADDRESS: FAX:
CITY: E-MAIL:
STATE/PROVINCE: ZIP/POSTAL-CODE: COUNTRY:

Credit Card Information:

VISA/MASTERCARD/DISCOVER (circle one) ISSUING BANK:
CREDIT CARD #: EXP.DATE:                             3 Digit CCV#:
NAME AS IT APPEARS ON CARD: AUTHORIZED SIGNATURE:

Products:

Qty.: Product Name: Product I.D. #: Color: Size (if applicable): Price:
           
           
           
           

SUBTOTAL ($) ____________
JEFFERSON CTY, COLORADO RESIDENTS ADD 4.2% SALES TAX ____________
COLORADO RESIDENTS ADD 3% SALES TAX ____________
No Tax on Orders Shipped outside of Colorado

Shipping Method:Domestic Insured Rates (Circle One)

 Order Amount UPS Grnd UPS 2nd Bus. Day UPS Next Bus. Day Military(APO/FPO)
Parts $0-50 6.00 11.00 15.00 10.00
Parts $50+ 9.00 14.00 18.00 15.00
Wheels 20.00 40.00 60.00 15.00
Suspension Forks/Rims 12.00 15.00 20.00 20.00
Subtotal: $_________
Taxes (if applicable): $_________
Shipping: $_________
Grand Total: $_________