Your Name:  

Address:

City:                                                                   State:                                       ZIP:                   

TEL. Day:                                                         Evening:                                                       Cell:

FAX:                                                                   E-mail:

YEAR

MAKE

MODEL

STYLE

LAST 8 VIN

LIC.  State & No.

SHIPPER / ORIGIN INFORMATION:

DATE RANGE AVAILABLE FOR PICKUP :

NAME:

ADDRESS:

CITY STATE ZIP :

TELEPHONE NOS.:   DAY

                                     EVENING                                           CELL

CONSIGNEE / DESTINATION INFORMATION:

PREFERRED DELIVERY DATE, NOT BEFORE:

NAME:

ADDRESS:

CITY STATE ZIP :

TELEPHONE NOS.:   DAY

                                     EVENING                                          CELL

PAYMENT OF FREIGHT CHARGES:

Please initial, indicating your choice of payment method:

X

At time of shipment: Cash, Certified funds, Money Order.

X

At time of shipment: Credit Card (VISA, MC) (Your credit card will be charged at time the vehicle is received for shipping. Please complete and fax the charge slip.)

X

At time of delivery in Anchorage AK: Cash, Certified funds, Money Order, VISA or MC. (The C.O.D. option is available only on vehicles valued in excess of four times the freight charges.)