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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)_____  ___________________________________________________$_______$_______
SUB-TOTAL:$______
SHIPPING: ESTIMATED(Minimum of $16.00 or 15% whichever is more)$______
ADDITIONAL SHIPPING FOR HEAVY~OVERSIZE~FOREIGN to be determined upon shipment:$_TBD_
CALIFORNIA Residents ADD 8% SALES TAX:$______
   __ __ __ __~__ __ __ __~__ __ __ __~__ __ __ __*__ __ __
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
634 East Lockeford Street
Lodi, CA. 95240
_____________________________
_____________________________
_____________________________
Voice: (209) 365-6315
Fax:  (209) 365-6380
www.RamblerParts.com