PDM RACING FAX ORDER FORM

Fax this form to (604) 430-4513

 

** all fields must be completed and legible

*** Before you order review our terms and conditions page ***

 

Personal Info

 

 

 

 

First Name:

 

Middle Initial:

 

Last Name:

 

 

Business Name:

 

Dealer No:

Email Address:

 

* Email is very important as this is our #1 form of communication. Print CLEARLY

Full Shipping Address (including zip code or postal code):

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number:

 

Cell Number:

 

 

 

 

 

Vehicle Info

 

 

 

 

Vehicle Year:

 

Vehicle Make:

 

Vehicle Model:

 

Vehicle Bodystyle:

 

 

 

 

 

Payment Info

 

Only VISA and MASTERCARD accepted.

Name as it appears on the Card:

 

Credit Card Number:

 

Expiry Date (MM/YY):

 

Billing Address:

Billing Address must be the same as Shipping address. If you have a separate shipping address,

please register that address with your credit card.

 

 

 

 

 

 

 

 

 

 

 

 

Signed and agree to PDM’s terms and this order:

 

*order will not be processed without a signature. For Email orders, typing your full name in the box will signify a signature.

 

 

 

Qty.

Part #

Product

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


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Have you purchased from PDM before?

 

 

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