Battery Brain Fax Order Form
Fax Order To : 410-265-6801
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(Please print the form first and then fill it out) |
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| Date: | ___________________________ |
| Battery Brain for 12V (cars, trucks & vans) | Qt. ____ |
| First Name: | ___________________________ |
| Last Name: | ___________________________ |
| Street Address: | ___________________________ |
| City, State, and ZIP code: | ___________________________ |
| Country: | ___________________________ |
| E-mail address: | ___________________________ |
| Phone Number: | ___________________________ |
| Card Type: | ___Visa ___Mastercard ___Amex____Discover |
| Card Number: | ___________________________ |
| Expiration Date: | ___________________________ |
| In order to purchase BATTERY BRAIN, I hereby authorize RV Doctor by Collis Corp. to bill my credit card, and agree to pay to my credit card company, the amount of USD $_______________ | |
| Credit Card authorization: | ___________________________ |
| Signature: | ___________________________ |