DieselManor

DieselManor, Inc.
P.O. Box 86
Goffstown, NH 03045
Fax: (603) 497-3783
www.dieselmanor.com

Bill To:

Ship To:

same

Name:	.	Name:	.
Address:	.	Address:	.
	.		.
City, State ZIP:	.	City, State ZIP:	.
e-mail:	.	e-mail:	.
Phone:	( )	Phone:	( )

Order:

Item #	Item Description (include color, options, etc.)	Qty.	Price	Extended
.	.	.	$	$
.	.	.	.	.




.	.	.	.	.
.	.	.	.	.
* We will charge you the appropriate shipping amount for the shipping method you've selected, unless free shipping applies. We will not charge you any handling charge.			*Shipping
Shipping Method:			Total	$

UPS Ground UPS 3-Day Select UPS 2nd Day Air UPS Next Day Air

Vehicle Description: (Note: please indicate any unique factory features about your vehicle that would apply to the
products you ordered…e.g. Super Duty, Ext Cab, Int. Paint Code, etc. This will help insure you get the right product.)

Year:	.	Bed Size:
Make:	.	Cab Size:
Model:	.	Other:

Payment Info:
Note: These are the only forms of payment we accept (personal checks require an additional 2 weeks for processing).

Card #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Exp. Date:___ ___/___ ___ V-Code ___ ___ ___ ___

Credit Card V-Code:
For your security, and for credit card fraud prevention, we require the V-Code on your credit card. For more information and how to locate your V-Code click Here:

_______________________________________________
Signature of Cardholder…must match "Bill To" name above.

I authorize DieselManor, Inc. to charge the credit card number indicated above for the total above plus shipping. I certify that the credit card number and signature above agree to the "Bill To" name above and that, as such, I am an authorized signer on this card.