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• <br /> Pa e LIN cOLN <br /> 1108 W. Main St. Van Wert, Ohio 45891 866-313-5042 FAX 866-832-4430 <br /> www.statewideford.com • e-mail: aim @statewideford.com <br /> ORDER FORM <br /> Purchaser Fed Tax# <br /> Address <br /> City County State Zip <br /> Contact Name Phone# <br /> P.O. # E-mail <br /> 2016 Ford Utility Police Interceptor <br /> Back Up Camera Location (please check one) CenterStack 87R Rear View Mirror <br /> Quantity Code Color Exterior Color Interior Price Per Unit <br /> Base Utility K8A $25,429.00 <br /> Options: <br /> Delivery: YES NO Delivery Charge: $0.25 x mile (s) = <br /> Round Trip $60.00 minimum <br /> Total Unit Cost$ <br /> All orders must be accompanied by a Purchase Order and a completed W9 Form or they CAN NOT be processed. <br />