HI-TEK Racing
CHIP ORDER FORM

*Name:
*Address:
*City:
*State: *Zip Code:
*Phone:
*Email Address:
Credit Card:
Card Number:
EXP Date:
Date of Birth
Age
If you prefer - You may submit order on-line and call or fax your credit card.
Phone: 203-337-6132  Fax: 203-375-6715
This is not a secure order form.
SHIP TO: IF DIFFERENT FROM BILLING ADDRESS ON CARD
Name:
Address:
City:
State: Zip Code:
Remarks:

$29.00 Total Price - Includes Shipping!
Shipped USPS First Class.
We will email you to confirm the receipt of your order.

Orders are shipped directly from Super Race Systems.
THANKS!

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