FAX ORDER FORM



Please fill out this form completely, then print it out, and fax it to 203-791-0253
(Please Note: You may type in your credit/shipping information below then print the document)
Qty. Product Description SKU # Price Each  Total
         
         
         
         
         
Sub Total:  
CT 6% tax:
Total:
billing Information - shipping included (u.s. orders only)

Circle One:   Visa | MasterCard | American Express | Discover
Name as on Credit Card
Company
Billing Street
Billing City, State, & Zip Code
Billing Phone Number
Credit Card Number 
(incl. 3-4 digit code)
Expiration Date
Email Address

Shipping Information 

  Check Here if Same As Billing Address
Full Name:
Company:
Shipping Street Address:
City, State, & Zip:
Phone Number:
 

Card Holder Signature:
__________________________

Thank you   -   HPT Motorsports, LLC     fax 203-791-0253