Galvin's AMC Rambler Parts Order Form

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GALVIN'S AMC RAMBLER PARTS - ORDER FORM

NAME:_____________________________________ DATE:

ADDRESS:__________________________________ NOTICE: $5 charge 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 $12.00 or 10% whichever is more)					$______
California Residents add 7.75% 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 St.
Lodi, CA. 95240

______________________
______________________
______________________

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