ORDER FORM CUSTOMER PLACING ORDER Contact Name: Contact Phone: Email: Street: City: State: Zip: ORIGIN INFORMATION Contact Name: Contact Phone: Other Phone: Other Phone: Email: Street: City: State: Zip: DESTINATION INFORMATION Contact Name: Contact Phone: Other Phone: Other Phone: Email: Street: City: State: Zip: VEHICLE INFORMATION VEHICLE READY DATE: Last 6 of your VIN (Vehicle Identification Number) Year Make (ex: Ford, Chevy) Model (Ex: Taurus, Camaro) Color Shipping Cost Total Due Upon Delivery VEHICLE RUNS?         YES         NO PAYMENT INFO: Check (Payable to "United Auto Express, Inc.") Visa         Master Card         American Exp. Card Number Expiration Date (MM/YY) Cardholder Name Cardholder Adress: Street City State Zip Card Holder's Signature (If Different than Customer): X I have received, read, and understand the Shipping Agreement General Provisions of United Auto Express. I agree to the Shipping Agreement and I agree to pay the above amount. I understand that my deposit is refundable under the conditions in the Shipping Agreement. I understand that the COD amount must be paid upon receipt of the car, and that only Cash, Money Order, or Cashiers Checks are accepted. Customer's Signature X   Date  Mail To: United Auto Express, Inc. 7250 S. Waterway Dr. Miami, Florida 33155 MC: 577613 Fax To:(305) 402-0565