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County Imports Gas Scooter, ATV's, etc

 

 

10350 Mission Gorge Rd.

 

Santee, CA 92071

 

TEL: 702-628-5468

To Print: press "CTRL" + "P"

FAX: 619-449-9064

 

claims@countyimports.com

Method of Payment

Dealer         OR         Customer
  Name     Invoice No.
  Address     Date
  City,State,Zip     Sales Rep
Credit Card Wire Direct Deposit
Fee Paid by credit card
are subject to a
convenience fee 3%
of the total transaction
amount incurred.		   Amount:
$
 
  3% Conv. fee:
$
 
  Total:
$
 

Credit Card - Detail Information

Company's name appears on the card
Card holder's name appears on the card
Card #:
 
Expiration:
 
CVV2:
 
Card billing
Street #:
 
Card billing
Zip code:
 

I want this order to be shipped by       San West, Inc.

I am the card holder on this account and authorize the above amount to be charged by CountyImports.com - San West, Inc. SIGN:  Date:

    Fill out, Print, CTRL P - Please sign and fax back this form to 619-449-9064
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