Galvin's Rambler Parts - Order Form

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 $21.00 or 18% 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