Zertifikat Order Form

Mercedes Benz Classic Center

One Mercedes Drive

Montvale, NJ 07645

866-622-5277

Fax 201-802-2151

Classicparts@mbusa.com

Name______________________________________ Date________/20___

Phone#___________________ Fax#_______________________________

E-mail _______________________________

Chassis/Vin number ______-______-____-______________

Examples: 198-042-45-00000 / 121-042-10-000000

Ship To: ___________________________________________________________________________

Street Address_____________________________________________________________________

City_________________________________________State___________ZIP____________

Certificate price $ 100.00 USD plus applicable sales tax

S&H $ 8.00 USD (Fed Ex)

Credit Card Type______________________

Credit Card # _________-_________-__________-__________ Exp. date ______/______

Customer Signature ________________________________________________________

Please allow 12 weeks for delivery

IMPORTANT: This application form must include a copy of the Vehicle Title

Date received _______________(MB Internal use only) Via: Mail _____ Fax_____ E-mail_____

Control number _______________(MB Internal use only)

02/03