Autoclockrepair Shipping invoice

Name:
Date Shipped:
Item Type (year/model):
Email Address:
Street Address:
City:
State:
Zip Code:

Please circle which options you paid for
Payment (paypal / check)
Shipping (priority/ first class)
Insurance (yes/no) $3.50 for $200 of coverage

Notes (phone number, etc):

If paying by check please make it payable to Steve Titus

Thanks!

Steve Titus
Autoclockrepair		
91 Galliac Dr
Rising Sun, MD
21911