Customer Name:

Ship to Address:

City:   State:   Zip:  

Country:                Phone:     Date:  

E-mail address:              

This adapter will be used on my:

Car Make:    Year:     Engine:   cid.          

How did you hear about this product?    

                                                             Price Each                            Merchandise Total    

Quantity Ordered:            X            $ 59.00              =            $    

Shipping free (within US)                                                                        free

International Shipping (add $ 28.00 each) if applicable:                $      

                                                                                           TOTAL:  $  

Sorry, we do not accept electronic payments.

We ship via US Post Office Priority Mail. Make sure the address you provide is deliverable.

Make checks or money order, in US funds, payable to  "David M. Homstad".

Type in the blanks above and print a copy of this form. Mail with payment to:

     David M. Homstad

     7220 Upper 164th St. W

     Rosemount, MN  55068