BAGTEC  LLC
Please print this page, fill out every space and fax to the number listed below

As it appears on Credit Card                                                         (Only American Express NOT accepted)

First Name_________________Middle Initial_____Last Name_____________________________

Credit Card # __________  __________  __________  __________ Expiration Date:  ______  ______

Verification Number ___  ___  ___ 3 Digit Code on back of card

Billing Address:

Address ________________________________________________________________________

City _____________________________________ State _______ Zip Code _________________

Shipping Address (if different than Billing Address)

Company / Name _______________________________________________________________

Address _______________________________________________________________________

City _____________________________________ State _______ Zip Code _________________

Home Phone (          ) _______-______________ Work Phone (          ) ______-_____________

Cooltec Bag - Quantity ___ x $90.00 = $__________ + S & H $10.00 = ______  Amount Due __________
Daytec Bag - Quantity ___ x $84.99 = $__________ + S & H $10.00 = ______  Amount Due __________
Classic Tour Bag - Quantity ___ x $130.00 = $__________ + S & H $10.00 = ______  Amount Due __________
Custom Roll Bag - Quantity ___ x $100.00 = $__________ + S & H $10.00 = ______  Amount Due __________
Full Dresser Bag - Quantity ___ x $200.00 = $__________ + S & H $15.00 = ______  Amount Due __________
Grand Roll Bag - Quantity ___ x $120.00 = $__________ + S & H $10.00 = ______  Amount Due __________
GranTour Bag - Quantity ___ x $170.00 = $__________ + S & H $15.00 = ______  Amount Due __________
Mini - GranTour Bag - Quantity ___ x $150.00 = $__________ + S & H $10.00 = ______  Amount Due __________
GranThrowover Saddlebags - Quantity ___ x $200.00 = $__________ + S & H $15.00 = ______  Amount Due __________
Grantraveler Bag - Quantity ___ x $190.00 = $__________ + S & H $15.00 = ______  Amount Due __________
Tombstone Bag - Quantity ___ x $150.00 = $__________ + S & H $10.00 = ______  Amount Due __________
Tour Trunk Roll Bag - Quantity ___ x $130.00 = $__________ + S & H $10.00 = ______  Amount Due __________
Ultra Tour Bag - Quantity ___ x $130.00 = $__________ + S & H $15.00 = ______  Amount Due __________
Heel Guard - Quantity ___ x $65.00 = $__________ + S & H $5.00 = ______  Amount Due __________
Fold Down Luggage Rack #1528 - Quantity ___ x $125.00 = $_______ + S & H $5.00 = ______  Amount Due __________
Fold Down Luggage Rack #1529 - Quantity ___ x $125.00 = $_______ + S & H $5.00 = ______  Amount Due __________

I agree to pay above Total Amount Due according to card issuer agreement.                  Total Amount Due____________

Card Holder Signature___________________________________________________________

Fax ( 734 ) 533-6109   Phone 1 - 337 - 296-7252   E-Mail   BAGTEC Home