| Mail In/Fax Order Form (Print out this page) |
| Ampco Lubricators LLC P.O. BOX 1468 New Milford, CT 06776 Fax: 860-355-8357 |
| Phone: 860-355-5706 Email: info@ampcolubes.com |
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Method of Payment
____ Certified check or money order enclosed
____ Visa ____ MasterCard
Expiration Date: _____ / ________
Account Number: _______________________________________ * ________
*If you are faxing this form, please include the 3 digit security code found on the
back of your card
Signature: __________________________________________________________
Please print the following
Name: _____________________________________________________________
Address: ___________________________________________________________
City: _____________________________________ State ______ Zip __________
Daytime Phone: _____________________________________________________
Other Phone: _____________________________________________________
E-mail address: ______________________________________________________
How did you hear about us? ___________________________________________
____ Certified check or money order enclosed
____ Visa ____ MasterCard
Expiration Date: _____ / ________
Account Number: _______________________________________ * ________
*If you are faxing this form, please include the 3 digit security code found on the
back of your card
Signature: __________________________________________________________
Please print the following
Name: _____________________________________________________________
Address: ___________________________________________________________
City: _____________________________________ State ______ Zip __________
Daytime Phone: _____________________________________________________
Other Phone: _____________________________________________________
E-mail address: ______________________________________________________
How did you hear about us? ___________________________________________
