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Name:_____________________________________ Shipping Address:____________________________ __________________________________________ City:______________________________________ State:__________________ Zip:______________ Daytime Phone #: (______)_______-_____________ Home Phone #: (______)________-______________ Make personal checks payable to: Moped WorldŽ. Shipping address above must be "on file" at your bank. All information is kept confidential. ALL checks must clear before shipment. We check the validity of ALL checks. Fraudulent checks are immediately turned over to local SS Branch & USPS. We will call to verify receipt of fax within 24 hours. Remember to write down your bank's telephone number and sign this form before faxing it in. |
_________________________________________ Cell Phone Number (optional) _________________________________________ Pager Phone Number (optional) _________________________________________ How did you hear about us? _________________________________________ Your Bank's Telephone Number (w/area code) _________________________________________ Your Signature .: .
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