Bicyclecart.com - Order Form

1. Print this form   2. Fill it out   3. Fax to 574-534-8687

Full Name_______________________________________________

Shipping Address:_________________________________________

_______________________________________________________
Note: Your shipping and credit card billing address must be the same!

E-mail Address:___________________________________________

Telephone and/or fax number:________________________________

Circle card type:        Visa  /  MasterCard  /  Discover

Name as it appears on card:________________________________

Card Number:_____________________________________________

3 digit Card security code:___________ What is it?

Expiration Date:____________________________________________

Order:
Bicycle Cart(s):
(number of carts
x $300 each)

Additional Hitches:
( x $12 each)
Each cart comes with one.

Subtotal:

Indiana residents
Add 7% tax
(subtotal x .07)

Shipping Cost:
(Shipping Zones Table)

Grand Total:
(subtotal + tax + shipping)


$__________



$__________



$__________


$__________



$__________


$__________
                       Example:


1 cart(s) x $300 =



1 additional hitch x $12 =



Subtotal:


IN Tax:


Shipping:


Grand Total:


$_300___



$_12____



$_312___

$__0____


$__42___


$_354___