Sequential Turn Signal Order Form


First Name_______________________________________________________

Last Name________________________________________________________

Street___________________________________________________________

City______________________State___________ Zip Code______________

Email____________________________________________________________

Ship to Address:   if different than above

Name_____________________________________________________________

Street___________________________________________________________

City______________________ State___________ Zip Code_____________

Year of Vehicle:_________Make:____________ Model:________________

  
Quantity of kits ordered ________  x  $159.00  = ________________


 
Please add $12.00 S&H per order for the continental US =   $12.00
For orders outside continental US please
contact us by email for postal rates

                                         Total  = ________________

       * Please allow 2  - 4 weeks for delivery

Mail check or money order payable to:  Jerrys Electronics

All orders will be processed upon arrival,
but will not ship until your check clears the bank.

And mail completed form to :    Jerrys Electronics
                                2525 Lagonda Ave.
                                Springfield, Ohio 45503