ORDER FORM (Attach more pages if needed)

Name___________________________            Ship to: ______________________
Company________________________                        _______________________
Address_________________________                        _______________________
City____________ State_____ Zip_______                  _______________________
Phone___________ Fax______________

Quantity        Part Number                                        Description
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Shipping: 
[  ] STANDARD (Rieken's Racing Picks) [  ] UPS  [  ] Fed Ex  [  ] Spee Dee  [  ] USPS Priority Mail
[  ] Ground  [  ] NEXT DAY  [  ] 2ND DAY
  [  ] 3RD DAY  [  ] International
Credit Card:
    Name (as it appears on card)_____________________________________

    [  ] Discover Card    [  ] Master Card    [  ] Visa

   
Account #___________________________ Expiration___/___  V-Code____

    Signature___________________________  
(The V-code is a 3 digit# on back of the credit card.)
Mail to:  RIEKEN'S RACING                                           Fax to our 24 hour fax line:
                Order Department                                             319-377-2139
                365 7th Ave.
                Marion, IA 52302 USA

SPECIAL INSTRUCTIONS: