629 NW 7 Avenue

Ft. Lauderdale, Florida 33311

Telephone:  954-523-7883

PLEASE FAX THE FORM BACK TO:  954-523-7887

CUSTOMER NAME (Print)__________________________________________             

CUSTOMER BILLING ADDRESS: _____________________________________

_____________________________________

CUSTOMER TELEPHONE: (____) ___________________________________

CREDIT CARD INFORMATION:

(Must include Cardholder Name, Card Number, Card Name, Expiration Date and 3–digit Card # (on the back of the
card or for Amex 4 digit front of card)

(1)_____________________    ___________________________   ________    ____  _______

       Cardholder Name                  Card Number                                      Expiration          3-digt        Card

          Date                 Code         Type

(2)_____________________    ___________________________   ________    ____  _______

       Cardholder Name                  Card Number                                      Expiration      3-digt    Card

         Date               Code    Type

I, HEREBY authorize We Got It Used Auto Parts to act upon my instructions received by telephone or any other means to charge
any of my credit card accounts listed above for the payment in the amount of $ _________________.  By signing this form I am fully
aware of the warranty information the part (s) I’m about to purchase hold.  I also understand that I am able to review the entire policy
online at www.wegotitauto.com and on the invoice provided with my shipment.    Products that are shipped are done at customer's
expense and risk, any loss or damage in shipping should be filed and claimed directly through the freight carrier. We assume no
responsibility for any loss, damage, freight cost and miscellaneous charges. WE GOT IT USED AUTO PARTS will not be responsible
for any labor cost incurred by the customer. We are not responsible for improper installation and/or labor charges for installation or
removal of defective parts.  We do not assume towing, shipping or transportation cost.

Year/Make/Model:________________________ Part Requested:__________________

Customer Signature: _______________________ Date: ________________

SHIPPING ADDRESS:       ______________________________________

r Residential r Business

                                                ______________________________________

                                                ______________________________________

                                                ______________________________________

                                                Attn:__________________________________

                                                Telephone:_____________________________(Required)