GMP Diecast Engines Mail-In Pre-Order Form
Print Out - Fill Out - Mail In (US Funds Only)

• Send me the following Keith Black 392 Hemi Engine(s): @ $199.95
• $ ____________ Total Cost Engines Ordered
• $ ____________ Shipping & Handling (14 lbs) for each piece ordered ($18.75) -- (Canada $30.50) (Europe-UK $65.00)
  SOLD OUT
•  

________________________________________________________________

Name: ___________________________________________________________

Company: ________________________________________________________

Shipping Address: __________________________________________________

City: _____________________________________________________________

State: _______________________________________ Zip Code: _____________

Mailing Address (if different): _________________________________________

Phone (Days): ____________________ Phone (Eves): ______________________

e-mail Address: ___________________________________________________

Special Instructions:________________________________________________

Select Payment Type: (include payment with form)

Check Payment Type: _____Cashiers _____ Money Order _____ Certified Check
_____ Personal Check
Check Number: __________ (personal checks need to clear our bank before order is shipped)

For Credit Card Payments Diecast: Credit Card Order

Make checks payable to: Left Coast Web Graphics

Mail Order Form To:
Left Coast Web Graphics
Diecast Series
210 SW Pine St.
Grants Pass, OR 97526

Phone: 541-955-7130    E-mail: GMP Diecast

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