RA Parts Order Form

(301) 775-8134   Monday - Friday 10- 6 pm Eastern Time Zone

POB 405 Simpsonville, MD 21150

PLEASE CALL FOR CURRENT PRICING AND AVAILABILITY BEFORE ORDERING.

Please print and complete this form for use with your order.
Name:  ______________________________________ Daytime Phone:  ____________________
Email Address:  __________________________________________________
Billing Address
Street Address:  ____________________________________________________________
                         ____________________________________________________________
City:  ________________________________________
State:  ______________________________ Zip Code:  ____________________
Shipping Address
(We do not ship to APO or FPO addresses.)
  Check here if same as Billing Address.
Street Address:  ____________________________________________________________
                         ____________________________________________________________
City:  ________________________________________
State:  ______________________________ Zip Code:  ____________________
Payment Method
  Money Order/Certified Check      (Make money order/check payable to RA Parts)
  Credit Card                 VISA            Mastercard
          Credit Card Number:  __________ - __________ - __________ - __________
          Expiration Date:  _______ / _______
          Card Verification Number:  __________   (last 3 digits on back signature panel)
          Name of Cardholder:  _____________________________________________
          Signature:  _____________________________________________
Description Qty. Unit Price Extended
       
       
       
       
       
       
       
       
       
       
       
       
Merchandise Subtotal:   ____________________
Add Shipping and Handling:  
(Refer to Order Information for Charges)		 ____________________
Maryland Residents Add 6% MD Sales Tax:   ____________________
Total Enclosed:   ____________________
Please refer to ordering instruction section for complete ordering information, return policy, damage shipment, warranty and warnings.
Please mail your order to:   RA Parts, Inc., Box 405, Simpsonville, MD 21150
Thank You For Your Order