Santa Ana Plating Easy Ship Order Form

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Customer Shipping Form - Please complete form and enclose with your order.

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First Name: _____________________

Last Name: ______________________________

Street Address: ____________________________________________________________

City: _______________________________________ State: ______ Zip: ______________

Phone Number: ( __ __ __) __ __ __ - __ __ __ __

E-mail Address: ____________________________@______________________________

Please List Parts Being Shipped	Quantity
1.________________________________________________________________	_____
2.________________________________________________________________	_____
3.________________________________________________________________	_____
4.________________________________________________________________	_____
5.________________________________________________________________	_____
6.________________________________________________________________	_____
7.________________________________________________________________	_____
8.________________________________________________________________	_____
9.________________________________________________________________	_____
10._______________________________________________________________	_____
11._______________________________________________________________	_____
12._______________________________________________________________	_____
TOTAL NUMBER of Parts Being Shipped:	_____

Continue list on backside of paper or print and attach additional forms, if needed.

Please note any special instructions e.g. repair needs, desired finish (polish only, chrome, gold, zinc, brass, etc.):

_________________________________________________________________________

Date requested for completion: ______/___/_____ (month / day / year)

Method of Payment:

COD (money order / cashier's check)

(check one)

Visa

MasterCard

Credit Card Number: __________________________	Expiration Date: ______ / ______
		( mo / yr)

Please make sure all parts are disassembled. You must notify us of any repair needs prior to processing, or items may not be repaired.

SHIP TO: PCA Industries/Santa Ana Plating; 1818 East Rosslynn Avenue; Fullerton, CA 92831
Phone: 714.871.2490 Fax: 714.738-5288
(We recommend UPS for tracking and accountability)