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Southwest Marine Mail-In Order Form

Please call (239) 332-2166 to check availability of items requested before sending in payment.

Mail to: Southwest Marine, Inc.               ***Please send an email to: info@southwestmarine.com
             4655 Cummins Court                      informing us of an order being mailed in.***
             Fort Myers, FL  33905

    Shipping Information

    Name:
    Address:

    City/State:

    Zip Code:
    Phone:

    Email:

    Engine Details

    Please indicate your system details so that we can verify what you have ordered is indeed the model number listed below is what you require. Fill in all available information.

    Make:
    Model:
    Year:

    Horsepower:
    Model No.:
    Serial No.:

    Requested Items

    Qty.   Part Number       Description                       Price (USD)    Total

    Subtotal:

    Florida Residents add 7% Sales Tax:

    Total Due:

    Credit Card Information

    If sending a money order or cashier’s check, make it payable to Southwest Marine, Inc. Otherwise, please fill in credit card information below.

    Name as it appears on your credit card statement:

    Address as it appears on your credit card billing statement:

    (if this is the same as the shipping address, there is no need to fill this out.)

    City/State:

    Card Type:

    (Circle one)

    Card Number:

    Visa

    MasterCard

    Discover

    Zip Code:

    Expiration (mm/yy):

    /

    By signing below you authorize Southwest Marine, Inc. to charge the designated credit card for the amount listed above.

    Signature:

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