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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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