Total:  $ ____________ + $ _________ (S&H) = $ ___________

Sold to:                                                              Ship to:  _____same
Name: ____________________________       Name: ______________________________

Address: ___________________________      Address: ____________________________

City: __________________ State: ________    City: __________________ State: ________

Zip: ___________ Phone: _______________    Zip: __________ Phone: _______________

Signature: ___________________________ Title: __________________ Date: __________

Orders may be Faxed or sent by electronic mail or by US Mail. If Faxed, clocks will be reserved 
pending your payment.  Checks held 10 days to clear. Returned Check Fee is $30.

Send Payment to:  Roadhouse 66       P.O. Box 1995       Westerville, Ohio      43086-1995
www.roadhouse66.com   dave@roadhouse66.com  Office &  Fax: 614-890-3863