******  SEILER MARINE ORDER FORM  ******

Note:  Please send an email letting us know that your order is on the way.

Send to:   Seiler Marine
           P.O. Box 36382
           Panama City, FL 32412-6382

** SHIPPING INFO **
Name:
Signature:
Address:					
City:                         State:           Zip:
Phone Number: (   )    -
Email Address:

** PAYMENT METHOD **
Check One: 
__Visa  __MasterCard  __American Express  __Money Order
__Personal Check  __Cashier's/Certified Check 
Note:  Orders are held until personal checks clear.

** CREDIT CARD INFO **
Name Card is Billed to:
Address Card is Billed to:
City:                         State:           Zip:
Card Number:
Expiration Date (mm/yy):
(Be sure to check card type under Payment Method)

** MOTOR INFO **
Make:                         Year:            HP:
Model Number:                 Serial Number:
Number of Cylinders:
Type: __Outboard   __I/O   __Inboard

** PARTS NEEDED **
QTY  PART#        DESCRIPTION                  PRICE EACH     TOTAL
___  _____________ ____________________________       .           .
___  _____________ ____________________________       .           .
___  _____________ ____________________________       .           .
___  _____________ ____________________________       .           .
___  _____________ ____________________________       .           .
___  _____________ ____________________________       .           .

                                             Subtotal:            .
                      FL Residents Add 6.5% Sales Tax:            .
                                             Shipping:            .
                                                TOTAL:            .