ORDER FORM

Name:_________________________________
Address:_______________________________
City:__________________________________
State/Prov:_____________________________
ZIP/Postal Code:________________________
Phone: ________________________________
Car year & body type_____________________

[ ]with A/C  [ ]Slant 6 K-member  [ ]V-8 K-member
[ ]Automatic [ ]Power Steering [ ]Manual Steering

Check engine to be installed: [ ]273/318 [ ]340/360 [ ]361/383/400
                              [ ]440/413/420 Wedge  [ ]426 HEMI

Enclosed is a: [ ]Check [ ]Money Order	 

Charge my credit card:[ ]Visa [ ]MC [ ]Amex [ ]Discover
Card #_____________________________ Expires____________

Cardholder Name ______________________________________ 

Signature  ____________________________________________ 

(WA State residents only, 9.8% on Product & S&H Total)
|----------|----------------|--------------|-----------|
|Quantity  |	Description |	Unit Price |	Total  |
|----------|----------------|--------------|-----------|
|          |                |              |           |
|----------|----------------|--------------|-----------|
|          |                |              |           |
|----------|----------------|--------------|-----------|
|          |                |              |           |
|----------|----------------|--------------|-----------|
|          |                |              |           |
|----------|----------------|--------------|-----------|
    (Order by Phone or Fax)      Sub Total |           |
      Tel: 1-206-364-7151                  |-----------|
      Fax: 1-206-440-5464         Shipping |           |
                                           |-----------|
        Visa/Mastercard          Sales Tax |           |
       American  Express                   |-----------|
           Discover                  Total |           |
                                           |-----------|

Make check or MO payable to:
Schumacher Creative Services - 2025 NE 123rd, Seattle, WA 98125