Total: ______ COD ______ 30 days  $ __________ + $ _______(S&H&I) = $ ___________

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.
Delinquency Charge is 1 ½% per month on all past due balances. Returned Check Fee is $30.

Send Payment to:  Roadhouse 66       P.O. Box 1995       Westerville, Ohio      43086-1995
www.roadhouse66.com   dave@roadhouse66.com  Phone: 614-989-4515  Fax: 614-890-3863