Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State
Zip/Postal Code
Daytime Phone
Cellular Phone
E-mail

Please provide the following ordering information:

Number of units:
X $299.00 / Unit:
Shipping and Handling: add $14.95 / unit:
Total Amount Due:
Promotional Code	Applicable changes will be made on final invoice

 

	BILLING
Credit Card	VISA MasterCard American Express Discover
Cardholder Name
Card Number
Expiration Date

Important Notice: Release and Waiver of Liability

By submitting this form, I verify that I understand that The Truck Gym is not to be used while the vehicle is in motion.  I know of, understand and appreciate the risks that are associated with the use of The Truck Gym. I understand that I am solely responsible for injuries incurred in its use and assume the risk and waive, disclaim, release and hold harmless Turnbull & Sons LLC dba The Truck Gym Company for any injuries incurred as a result of the use of The Truck Gym