Oilmen's Order Form

Order Form
Date

MonthDayYear
Date
Name

First NameLast Name
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Is this order for shipping, pick up or delivery?

Pick upShippingDelivery within a 15 mile radius
Products Needed:
Product:
Size: Quantity:
Notes:
Product:
Size: Quantity:
Notes:
Product:
Size: Quantity:
Notes:
Product:
Size: Quantity:
Notes:
Product:
Size: Quantity:
Notes:
Custom Hose

Please fill out the portion below for custom hose orders.
Type of hose needed (fuel delivery, tank drop, gas, pump, etc):blanks
Product used (gas, diesel, etc) blank
Hose ID Type a label
Hose Length:Type a label
Fitting/Ends Used Type a label
Fitting/Ends Needed:   Type a label
Do you need an appointment for hose installation, cutting or customizing to your vehicle?
If you answered yes, we will call you once your product is ready to schedule an appointment.
Additional Notes:
Thank you for your order!

Once your order is complete, we will call to arrange pick up or delivery. For shipped orders, we will send a confirmation email to let you know your order has been sent. Please watch your email for your invoice, prompt payment is appreciated.
Should be Empty:

Order Form