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MOPED WORLDŽ
Copyright Š Moped WorldŽ
MOPED WORLDŽ
ORDER FORM
(for customers paying by wire transfer)
FAX TO:
Name:_____________________________________

Shipping Address:____________________________

__________________________________________

City:______________________________________

State:__________________    Zip:______________

Daytime Phone #: (______)_______-_____________

Home Phone #: (______)________-______________


Make wire transfer payable to: Moped WorldŽ. All information is kept confidential. We will call to verify receipt of fax within 24 hours. No cover sheet needed. 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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