Chevy-EMS-Catalog-final - Page 23



248-546-0232
MasterCard
VISA
®
®
DISCOVER
®
CARD
Order Form
ORDER DATE:
CUSTOMER NAME:
SHIP TO:
PHONE: (
PHONE: (
)
)
VEHICLE INFORMATION:
YEAR:
MAKE:
WITH TRUNK:
WITHOUT TRUNK:
BODY STYLE:
STANDARD:
DELUXE:
MASTER:
ENGINE:
COMMENTS:
PART #
PAGE #
DESCRIPTION
QUANTITY PRICE EACH
AMOUNT
1
2
3
4
5
6
7
8
9
10
SUB TOTAL
MAIL TO: EMS Automotive
Box 510507
Detroit, MI 48151-0507
FAX TO:
248-546-0228
SHIPPING 15% OF ORDER ($10.00 MINIMUM)*
MICHIGAN RESIDENTS ADD 6% SALES TAX
TOTAL
*On large orders, call first.
PAYMENT INFORMATION:
CHECK
MONEY ORDER
MASTER CARD
CREDIT CARD NUMBER:
VISA
DISCOVER CARD
EXPIRATION DATE:
SIGNATURE:
51
93323 o.f. - Rev. 4 - 3/17





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