Billing/Contact Details:

First Name:		Last Name:
Address:
City:		State:	Zip:
Primary Phone:	( ) -
Secondary Phone:	( ) -
E-mail Address:

Billing:

Card Type:	MasterCard Visa
Credit Card #:
Expiration Date (MMYY):

Ship to:

First Name:		Last Name:
Address:
City:		State:	Zip:
Primary Phone:	( ) -

Shipping Method:

	Standard UPS
	2nd Day UPS
	Next Day Air

Qty	Components	Sizes	Color	Unit Price
	Take Off™ Pair			$40.00
	Take Off™ Kit			$79.95
	Take Off™ Partial Kit (right or left take off™)			$69.95
	Take Off™ Right Only			$25.00
	Take Off™ Left Only			$25.00
	Fork-Mountain Black		Black	$180.00
	Fork-Mountain Silver		Silver	$180.00
	Fork-Cross Black		Black	$180.00
	Fork-Cross Silver		Silver	$180.00
	Stem-Mountain Black	10 11 12 13 14	Black	$95.00
	Stem-Mountain Silver	10 11 12 13 14	Silver	$95.00
	Stem-Mountain Custom Color	10 11 12 13 14		$125.00
	Stem-Road Black	10 11 12 13 14	Black	$95.00
	Stem-Road Silver	10 11 12 13 14	Silver	$95.00
	Stem-Road Custom Color	10 11 12 13 14		$125.00
Qty	Apparel	Sizes	Color	Unit Price
	Jersey-short sleeve	X-small Small Medium Large X-large		$65.00
	Jersey-long sleeve	X-small Small Medium Large X-large		$75.00
	Shorts-Black	X-small Small Medium Large X-large		$60.00
	Socks	Medium Large X-large		$9.99
	Kelly® Oakland T-shirt	Small Medium Large X-large		$16.99
	Kelly® Mountainbike T-shirt	Youth Small Medium Large X-large		$16.99
	Sweatshirt-Black	Small Medium Large X-large		$29.99
	Sweatshirt-Grey	Small Medium Large X-large		$29.99
	Kelly® Whoop Ass			$5.00

Total Order	$
Plus shipping & handling (minimum charge is $5.00)	based on Weight, Zip code destination, Ship method Selected
Sales Tax (California Residents only 8.25%)	$

This is a Dealer order. I have provided my resale number to be eligible to receive Wholesale pricing on my order indicated herein. Resale #:

I give Kelly Bike, Co. approval to charge my credit card for items ordered plus applicable sales tax and shipping & handling.

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All Kelly® Terms & Conditions of Sale Apply. International customers are responsible for all applicable duties & taxes. Prices are in U.S. $.

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