Galvin's AMC Rambler Parts Order Form

GALVIN'S AMC RAMBLER PARTS - ORDER FORM

NAME:_________________________________ DATE:_

ADDRESS:____________________________________ NOTICE: $5 fee for P.O. Boxes

CITY _________________ STATE: ZIP: COUNTRY:_

Phone Number: Work/Cell Phone:_____

Make/Model:_________________ Year: Engine:

	Part #:	Description:	Qty.	Price:	Total
01.	__________	__________________________________	___	$______	$______
02.	__________	__________________________________	___	$______	$______
03.	__________	__________________________________	___	$______	$______
04.	__________	__________________________________	___	$______	$______
05.	__________	__________________________________	___	$______	$______
06.	__________	__________________________________	___	$______	$______
07.	__________	__________________________________	___	$______	$______
08.	__________	__________________________________	___	$______	$______
09.	__________	__________________________________	___	$______	$______
10.	__________	__________________________________	___	$______	$______
Subtotal:					$______
ESTIMATED Shipping(Minimum $12.50 or 10% whichever is more)					$______
California Residents add 8.75% Sales Tax:					$______
Total:					$______

Visa~ Master ~ Discover:______-_______-_______-_______- *______
     *IMPORTANT: LAST 3 DIGITS ARE ON BACK OF CARD
       CREDIT CARD EXPIRATION DATE: MONTH:______ YEAR:______

         Card Holder Signature: _________________________________

   NOTE: If billing address is different from shipping, please print below.
MAIL or FAX to:

Galvin's AMC Rambler Parts
634 East Lockeford Street
Lodi, CA. 95240

______________________
______________________
______________________

Voice: (209) 365-6315
Fax: (209) 365-6380
www.RamblerParts.com