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