FAX ORDER FORM


Please fill in ALL requested information and when complete click "PRINT" and the form should print to your printer. Fill in your credit card information and sign the form and fax it to 845-458-5527. Once received you will get a confirming phone call and / or email. If the shipping & handling field indicates "CALL", please call PulseParts.com to continue the order. If the items you need are not listed below please call us and we will take care of you by phone.


First Name

Last Name

Company Name

Contact Email Address

Phone Number

Fax Number
Shipping Address (No P.O. Boxes):


Street Address Line 1

Street Address Line 2

City

State

Zip

PARTS REQUIRED
PART NUMBER
ITEM DESCRIPTION
ITEM PRICE
QUANTITY
62-3333
Air Vent Assembly
$350.00 ea
62-3535
Retaining U-Clip
$20.00 ea.
62-3339
Expansion Tank
$385.00 ea.
BM-9077
Blower Assembly (FF models only)
$450.00 ea.
62-3394
Blower Motor only (FF models only
$350.00 ea.
BM-9098
Circulator Motor (UP26-64F)
$400.00 ea.
BM-9096
Circulator Motor (UP15-42F)
$185.00 ea.


Total Item Price


Indicate state to calculate sales tax
NY     NJ    Other 
Total Order Shipping and Handling
Total Cost of Order




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Thank you for your order. This form is your order confirmation and your payment form

Take a moment to confirm that your order and price totals are correct, and indicate any changes/corrections on the form.

Fill in all Billing Information Below

Sign the Form and Fax to the number below

Billing Information

Name on Credit Card

________________________________________________

Credit Card Billing Address

_______________________________________________

City________________

State______

Zip___________

Credit Card Type (Circle One)

Visa / MasterCard / Discover

Credit Card Number

__________________________________________________

Expiration Date

_________________

Signature

___________________________________________________

To Complete your order

Fax this form to Pulseparts.com at 845-458-5527

Please contact us if you have any questions. Phone:(845)527-5877 or Email: PulseParts@AOL.com