BXR Order

PHONE:(914) 364-0102                      BXR MANIFOLDS, INC.
FAX:      (914) 354-0859                         199 MCNAMARA RD.
PURCHASE ORDER #:               SPRING VALLEY, NY10977 

DUE TO INTERNET SECURITY ISSUES WE ARE NOT CURRENTLY ACCEPTING DIRECT ORDERS. PLEASE PRINT OUT THIS FORM AND FAX IT TO US WHEN COMPLETED.
PURCHASER 

NAME: _____________________________

STREET ADDRESS: ___________________________________

___________________________________

CITY/STATE/ZIP: _____________/__/_____
PHONE/DAY:  (_ _ _) _ _ _ - _ _ _ _
PHONE/EVE:   (_ _ _) _ _ _ - _ _ _ _

 SHIP TO 

NAME: _____________________________

STREET ADDRESS: ___________________________________

___________________________________

CITY/STATE/ZIP: _____________/__/_____ 

- NO PO BOXES - 
 
 
Payment Method 
Circle one
CASH:  PICK-UP UPS (COD) CERTIFIED CHECK MONEY ORDER MASTERCARD
 
If Paying by Mastercard only:
MASTERCARD#:   __ __ __ __  -  __ __ __ __  -  __ __ __ __  -  __ __ __ __
Expiration Date:       __ __  /  __ __  /  __ __


CARDHOLDER'S NAME(print clearly): ________________________________________


CARDHOLDER'S SIGNATURE: _____________________________________________ 

 
GENERAL INFO
ENGINE TYPE: 
 		 HEAD TYPE: 
 		 VEHICLE;  MAKE/MODEL/YEAR:
_________/_________/19__  __
 

 
APPLICATION 
Check all that Apply
STREET ROAD RACING DRAG RACING
 
 
Quantity
Description
Price
    Total    
  BXR 5.0L Manifold Base Kit: Manifold, Fuel Rails, Extensions and Fasteners,  Direct Drive Distributor; Specify:
A/C KIT   |    |           NON-A/C KIT   |   |
$1995.00*
  
  EMISSIONS KIT:
$529.70
  
  Fuel Line Kit
$199.95
  
  Air Inlet Kit
$99.95
  
  Lengthened Wiring Harness
$150.00**
  
  Heater Hose Kit
$34.95
  
  Vacuum Hose Kit
$19.95
  
  Fan Spacer Kit
$14.95
  
  Oil Fill Modification Kit
$9.95
  
  OTHER OPTIONAL KITS:    
  Air Conditioning Line Kit
$139.95
  
  AOD Kickdown Adapter Kit
$7.95
  
  Direct Drive Distributor, Specify:    A/C  |   |          NON-A/C   |   |
$499.95
  
CALL TO ADVISE ON SHIPPING PREFERENCES <--shipping  
*Cash or Certified Check - Manifold base Kit - $1895.00
TAX:(NY only)  
**Core Rebate for you old working Wiring Harness - $75.00 TOTAL:  
***Core Rebates given for your old Distributor and Crank Pulley - $100.00

PLEASE VERIFY ALL INFORMATION IS CORRECT BEFORE SUBMITTING ORDER!