Real Gaskets Tennessee
2506 Stateline Road
Elizabethton, TN 37643 U.S.A.
Phone: 800-635-7325

 Phone: (423) 543-6194
FAX: (423) 543-9772
Email:

RETAIL ORDER FORM
 
        
Purchase Order Number  -OR-
Registration Number

   
Ship To:
Name:
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as it appears
on credit card
      Date:
Address:   State:
Address:   Country:
City:   Postal Code:
Email:   Telephone:
        (Please include country code)

Part Number:
Qty.
Price
Total
$ ea.
$
$ ea.
$
$ ea.
$
$ ea.
$
$ ea.
$
$ ea.
$
$ ea.
$
TOTAL (SHIPPING NOT INCLUDED)    
$

PLEASE CHECK ONE OF THE FOLLOWING:

Send order with shipping charges added
    (no need to call to confirm shipping)

Call with total amount before sending order






PLEASE SHIP:

Parcel Post
Priority Mail
UPS Ground



UPS Blue
UPS Red
UPS COD


Credit Card Number:
(VISA or MASTERCARD only)

Expiration Date:

 

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