Fax Order Form

Print, Complete, and Fax to 212-202-3558

First Name:________________________
As it appears on your credit card		 Last Name:_________________________
As it appears on your credit card

Address:_________________________________

Address_________________________________
As it appears on your credit card

City:___________ State:___ ZIP:_____

Mailing address, if different from credit card address

Address:_________________________________

Address_________________________________

 City:___________ State:___ ZIP:_____
Phone: (____) _____________________ email:________________________________
PlateLocker = $9.95*
Shipping/Handling = $2.95
Total = $12.90

*Includes automatic registration with
StolenCarReports if your vehicle is ever stolen
(A $15 Value)

Credit Card: [ ] MC [ ] VISA [ ] DISC [ ] AMEX
 (Check One)
 Card #_______________________


Card Verification Number: _____________

(On the back of your card, locate the final 3 digit number)

Exp. ____________  

Thank you for your patronage

Please allow 8-10 business days for delivery
Questions: Contact us by email by sending a message to Info at this website address (platelockers.com)

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