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Purchase Order
Ship To:
DATE: ________________________
NAME: ___________________________________________________
ADDRESS: _______________________________________________
_________________________________________________________
PHONE NUMBER: _________________________________________
MAKE & MODEL AND BOLT PATTERN: ________________________
NAME OF WHEEL: _________________________________________
SIZE: _________________________
If you need chrome lugs & valve stems my cost is $35.
If so, include $35 and make note of lugs & valve stems.
Chrome lugs & valve stems fit the wheel and they do not leak.
You can not buy them this cheap.
Wheels are shipped
FREE OF CHARGE and they go UPS
Make Check Or Cashier Check Or Money Order Payable To:
FASTLANE
We also Accept Visa and Master Card. If paying by credit card please provide the following information.
Type of Card Visa ___________ Mastercard ____________
Card Number _______________________________________________
Card Expiration Date: ______________ 3 Digit Card Code __________
Name on Credit Card: __________________________________________
Please Note: Wheels can only be shipped to the address listed on the Credit Card Statement.
Fastlane Speed & Rod Shop L.L.C.
6130 Hodges St
Mission, KS 66205
(913) 302-0665
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