C.P.B. Services

Appliance Order Form

Brand Name :
Model Number :
Serial Number :
Part Number :	(If You Have)
Description of Part :
	Motor Description
VOLTS :
AMPS :
LRA :
FLA :
PHASE :
HZ :
RPM :
HP :
FRAME :
Length of Shaft :
Diameter of Shaft :
	Customer Information
Name :
Address :
City :
State :
Zip Code :
Day Phone # :
Evening Phone # :
	Credit Card Info.
Type :
(Other) Type :
Card Number :
Expiration Date :
Name on Card :
Amount :
Credit Card Service Through Pay Pal