Bay Auto Forms - page 12

Bay Auto Parts & Recycling Inc.
360 Atlantic Avenue
Bellport, NY 11713
Telephone: 631-286-4500
Fax: 631-286-4505
Billing Information
Name: _____________________________________________________
Address: ____________________________________________________
City: _______________________________________________________
State: ______________________________________________________
Zip Code: ___________________________________________________
Best Contact Telephone Number: _______________________________
(in case we have questions regarding your order)
Shipping Information: (If different from billing address)
Name: _____________________________________________________
Address: ____________________________________________________
City: _______________________________________________________
State: ______________________________________________________
Zip Code: _______________________
Address Type: (Please Circle One) COMMERICAL RESIDENTIAL
Item (s) being ordered/Other info:
Please be sure to include the Year, Make, Model
and Part (s) being purchased. Please list part number if applicable.
Credit Card Information
Total Price to be charged: $___________________
(if resident of NYS, please include sales tax in total) – If you need help, please call us.
Name on Card: ______________________________________________________
Card Type: (circle one) VISA
Card Number: _____________________________________ Expiration Date: __________
CVS Code (Security Code): _______________
Signature: ___________________________________________ Date: ________________
This form is required to be filled
out by our customers who are
paying via Credit Card for their
merchandise from Bay Auto
Parts & Recycling.
Orders will be processed within 24-48 hours
of receiving completed form.
PLEASE NOTE: All orders are sent
via UPS only. We cannot ship to
P.O. Boxes, so please be sure to
give a valid mailing address!
Customer Check List:
Please include with this form:
Photocopy of Drivers License
of Credit Card holder
Photocopy of Credit Card
Please be sure to read our Terms and
Conditions on our website, or consult
with your Sales Associate regarding the
terms of sale, be sure to check box
below when completing this form.
I agree to Bay Auto Parts &
Recycling Terms of Sales
Agreement and Authorize Bay
Auto Parts & Recycling to charge
my credit card for the Total Price
listed on this form.
Please return completed form,
a photocopy of your Driver’s
License of Card holder &
Photocopy of credit card (front
and back) to fax # 631-286-4505
Any Questions, please do not
hesitate to give us a call, we
appreciate your business!
1...,2,3,4,5,6,7,8,9,10,11 13,14
Powered by FlippingBook