The Fast Lane | home
Purchase
8142 U.S. Rt. 60
Ashland, KY 41102
606-928-1994
(phone or fax)
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Price
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Total Price
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$
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$
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$
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$
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$
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$
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$
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$
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$
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$
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$
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$
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$
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$
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$
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Total
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Shipping (Call for Price)
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Sales Tax (6%)
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Grand Total
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Name:__________________________________________________
Street Address:___________________________________________ City:__________________ State:______
Mailing Address (if different):________________________________ City:__________________ State:______
Home Phone Number:__________________________ Work Number:___________________ ext.________
Method of Payment: Money Order/Chashier's Check/Visa/Mastercard/Discover
Credit Card Number:__________________________________________ Expiration Date:________________
Cardholder:__________________________________________________
Signature:______________________________________________________________ Date:________________