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Name:____________________________________________________________________________________________________
Street :
_____________________________________________________________________________________________
City: ___________________________________ State: __________________ Zip: _____________
Home Phone #: ( ) Business Phone # ( )
Ship To: (if different from above)
Name:
______________________________________________________________________________________________
Street:
______________________________________________________________________________________________
City: ____________________________________ State: _____________________________________ Zip:
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Ordering:
Quantity Part # Description Unit
Cost Total Cost
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Method of Payment: (No C.O.D.’s) Circle One (MASTER CARD), (VISA), (DISCOVER)
CARD #_______________________________________________________________ exp. date
____________________
For Cashier’s Check or Money Order please list Driver’s license # /State:
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Call for appropriate freight charges .
Mail to: Total from above $ _____________
Jumpking, Inc. State Sales Tax (Texas only) _____________
901 W. Miller Road Handling Charge 5.00
P. O. Box 461806 Freight Charge _____________
Garland, TX 75041 UPS Charge _____________
Mail to:
Jumpking, Inc.
901 W. Miller Road
P.O. Box 461806
Garland, TX 75041
1914