DIXIE MARINE SALES ORDER FORM
To send via fax, print from your browser, fill in the correct information and fax it to (305) 232-0217
Questions? Call 1-877-232-2024         Note: * denotes required information
Ship To:
Name*     ___________________________________    Phone* _________________
Address* _________________________________        Fax  ___________________
City* ____________   ST* _________  Zip* ________  Country ______________
Email*___________________________

Johnson_____  Evinrude_____ OMC_____ Mercury_____  Yamaha_____

Item #     Qty     Description                          Unit Price   Ext. Price
________   _____   ___________________________________  __________   __________
________   _____   ___________________________________  __________   __________
________   _____   ___________________________________  __________   __________
________   _____   ___________________________________  __________   __________
________   _____   ___________________________________  __________   __________
________   _____   ___________________________________  __________   __________
________   _____   ___________________________________  __________   __________

       DO YOU WISH US TO:
     Quote prices for parts you have listed above? ___Yes  or ____No
or:  Place your order for parts as listed above?   ___Yes  or ____No
 

If placing an order, indicate method of payment, then fill out form as required.

Billing Options:  ___ Check/Money Order          ___MC     _____VISA   _____
*(Note: Checks and money orders must be received before order will be shipped)

Credit Card Info:
Account Holders Name: _________________________________
Billing Address: ________________________________________
Account #___________________________ _________________   
Expiration _________________     Security Code______________
Total Amount $__________

I hereby authorize Dixie Marine to charge my credit card for the amount of my order.  Including handling and shipping fees if they apply.

Signed ____________________________    Date __________________

You will receive an email confirming your order and the total price.
If you do not please call 1-877-232-2024