Print this page, fill it out, and mail it with your payment to:
Poli-Form Industries, 15 Grove St. #101, Watsonville, CA 95076.
| Sold To: | |
Ship To: | |
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| Address | |
Address | |
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| City/State/Zip | |
City/State/Zip | |
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| Phone | |
Phone | |
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Shipping Method:
 Best Way |
Truck |
| Air |
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| UPS (small parts only,
no fronts) |
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Payment Method:
| Certified Check |
Money Order |
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| VISA |
Mastercard |
| Card #________________________ | Exp._______ |
| Signature _____________________________ |
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| Qty. | Item (Specify Right Or Left If Appropriate) | Price |
Item Total |
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| Car Year & Body Type: |
Subtotal |
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| Engine Type: |
8.0% CA Sales Tax |
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| Other Relevant Car Info: |
Crating Charges |
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| Total Enclosed |
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Contact Poli-Form at 831-722-4418 or email us
