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Purchase Order

Ship To:

DATE: ________________________

NAME: ___________________________________________________

ADDRESS: _______________________________________________


PHONE NUMBER: _________________________________________

MAKE & MODEL AND BOLT PATTERN: ________________________

NAME OF WHEEL: _________________________________________

SIZE: _________________________


If you need chrome lugs & valve stems my cost is $35. 
If so, include $35 and make note of lugs & valve stems.

Chrome lugs & valve stems fit the wheel and they do not leak.
You can not buy them this cheap.

Wheels are shipped
FREE OF CHARGE and they go UPS

Make Check Or Cashier Check Or Money Order Payable To:


We also Accept Visa and Master Card. If paying by credit card please provide the following information.

Type of Card   Visa ___________    Mastercard ____________

Card Number  _______________________________________________

Card Expiration Date: ______________ 3 Digit Card Code __________

Name on Credit Card:  __________________________________________

Please Note:   Wheels can only be shipped to the address listed on the Credit Card Statement.

Fastlane Speed & Rod Shop L.L.C.
6130 Hodges St
Mission, KS 66205
(913) 302-0665

For More Information Contact:

Fastlane Speed & Rod Shop L.L.C.
(913) 302-0665

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FastLane Speed & Rod Shop L.L.C

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