Name___________________________
Ship to: ______________________
Company________________________
_______________________
Address_________________________
_______________________
City____________ State_____ Zip_______
_______________________
Phone___________ Fax______________
Quantity
Part
Number
Description
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
______
__________
_________________________________________
Shipping:
[ ] UPS
Ground [ ] UPS Next Day Air [ ] UPS 2nd Day
Air [ ] UPS 3 Day
[ ] Spee Dee Ground [ ] FedEx Ground [ ]
USPS Priority Mail
[ ] International
Credit Card:
Name (as it
appears on card)_____________________________________
[ ]
Discover Card [ ] Master
Card [ ] Visa
Account
#___________________________ Expiration___/___ V-Code____
Signature___________________________ (The V-code is a 3 digit# on
back of the credit card.)
Mail to: RIEKEN'S
RACING
Fax to our 24 hour fax line:
Order
Department
319-377-2139
365 7th Ave.
Marion, IA 52302 USA
SPECIAL INSTRUCTIONS: