AMC Logo Left Galvin's AMC Rambler Parts Banner Galvin's AMC Rambler Parts Phone number 209-365-6315 AMC Logo Right
Link to Facebook Link to LinkedIn

Galvin's Rambler Parts - Order Form

(PRINT, THEN FAX or MAIL) (HELLOFAX.COM TO SCAN & FAX)

NAME:__________________________________________________________         DATE:
ADDRESS:___________________________________________________________ ZIP CODE: _______________
CITY: _____________________________________ STATE:_________________ COUNTRY:_____________________
PHONE #:(__ __ __) __ __ __-__ __ __ __ CIRCLE 1: WORK/CELL/FOREIGN: __ __ __ __ __ __ __ __ __ __ __ __ __ __
Make/Model:_______________________________ Year: 19 ____ Engine:_______ DOOR-TAG: Model: ________-___
Part #:Description:Qty.Price:Total
01)_____ - ___________________________________________________$_______$_______
02)_____ - ___________________________________________________$_______$_______
03)_____ - ___________________________________________________$_______$_______
04)_____ - ___________________________________________________$_______$_______
05)_____ - ___________________________________________________$_______$_______
06)_____ - ___________________________________________________$_______$_______
07)_____ - ___________________________________________________$_______$_______
08)_____ - ___________________________________________________$_______$_______
09)_____ - ___________________________________________________$_______$_______
10)_____ - ___________________________________________________$_______$_______
11)_____ - ___________________________________________________$_______$_______
12)_____ - ___________________________________________________$_______$_______
13)_____ - ___________________________________________________$_______$_______
14)_____ - ___________________________________________________$_______$_______
15)_____ - ___________________________________________________$_______$_______
16)_____ - ___________________________________________________$_______$_______
17)_____ - ___________________________________________________$_______$_______
18)_____ - ___________________________________________________$_______$_______
SUB-TOTAL:$______
SHIPPING: ESTIMATED (Minimum of $17.00 or 16% whichever is more)$______
ADDITIONAL SHIPPING FOR HEAVY~OVERSIZE~FOREIGN to be determined upon shipment:$_TBD_
   __ __ __ __~__ __ __ __~__ __ __ __~__ __ __ __*__ __ __
Total:$______

*IMPORTANT: 3 DIGIT SECURITY CODE       EXPIRATION DATE: MONTH:__ __ YEAR:__ __

Name on Card _________________________________ Signature: ___________________________________

FOREIGN ORDERS: E-MAIL ADDRESS REQUIRED: ______________________________@_______________

NOTE: If billing address is different from shipping, please print below.

Galvin's AMC Rambler Parts
522 South 5th Street
Klamath Falls, OR 97601
_____________________________
_____________________________
_____________________________
Voice: (209) 365-6315
Fax:  (209) 365-6380
www.RamblerParts.com