Printable Order Form

PARTS/SERVICES ORDER FORM

SEND TO: (PLEASE PRINT)

NAME: ________________________
ADDRESS: ____________________
CITY: _________________________
STATE: _______________________
ZIP: __________________________
PHONE: _______________________

DATE: _________________________

INFO ABOUT YOUR FAN:
MODEL # ______________________
SERIAL # ______________________
COLOR (IF ORIGINAL) __________

PART NO.	DESCRIPTION	QUANTITY	UNIT PRICE	TOTALS

OTHER INFO. (SPECIAL INSTRUCTIONS):	Shipping - call 414-570-9908 for estimate	PARTS TOTAL
		S & H	Call for estimate
		ORDER TOTAL

PLEASE MAKE CHECKS OR MONEY ORDERS MADE PAYABLE TO:
RICH RACLAWSKI
And mail to address listed below.

THANK YOU FOR YOUR ORDER!

Prices subject to change without notice.

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Richard Raclawski
8340 S Golden Fields Dr
Oak Creek, WI 53154
Home: (414) 570-9908 Cell: (414) 507-2474
rsraclawski@att.net