Order By Mail Form

Mail order form

Use this form to place your order by mail. Either type in your information and print the form, or print the form and write in your information. Send it to the address at the bottom of the page.

Shipping information

Name First Last

Address

City State Zip

Phone -
Daytime	- -
Evenings	- -

E-mail -

(Please include your e-mail address so we can notify you when your order has been shipped.)

Item	Quantity	Cost Each	Total










SUB TOTAL
SHIPPING AND HANDLING **
TOTAL

Fill in your truck information here

Year Make Model

(If writing your information in, circle the choice(s) below that apply to you.)

Regular Cab Extended Cab Crew Cab

Transmission -

Manual Auto 2wd 4wd

Special handling instructions -

Billing Information -

Credit Card info -

Visa MasterCard American Express

Card Number - - - - Expiration Date - /

Name on Card -

Billing Address (if different from shipping address)

Name First Last

Address

City State Zip

OR

Make money orders/checks payable to "Diesel Performance Specialists, Inc." Orders shipped upon arrival if made with a bank check or money order. Orders made with personal checks (US banks only) may be held until funds clear.

Please mail your order to -

Diesel Performance Specialists, Inc.

P.O. Box 152

Saranac, MI 48881-0152

** For Orders over $500, add $25 shipping. For orders under $500, add $15.