NAME
______________________________________________
(Please Print )
STREET Address __________________________________________________
CITY
_________________________________________________
STATE
_________________________________________________
ZIP
CODE
___________________________
PHONE#
(_________) _____________________________________
Try to let us know
what you need here.
SCOOTER Make______________________
Model _______________________
PART NAME_______________________________________________________
PART# (if available)__________________________________________________
Part Discription ( where dose it fit , what does it do, how long is it
ect.?)
____________________________________________________________________
____________________________________________________________________
Quantity Needed ____________
Price
$________________
SHIPPING/HANDELING $________________
TOTAL
$________________
Send your money order and this form to:
Elescooterparts
PO Box 1580
Selma, AL 36703