ORDER BLANK

ORDER BLANK

93 Border Street West Newton, Mass 02465 Information: 1-617-244-1118 Orders: 1-800-457-1250

Catalog Number

In a hurry? Not really sure of what you need? Order by telephone!

Most orders shipped same day. Fax: 1- 617-244 -1164

Email: orders@

Ship To: (Please print)

Year

Make

Model

Shipping Address Mailing Address if different

Body Style -- Coupe, Sedan, 1/2-Ton, Wagon, etc.

Number of Cylinders 4, 6, or 8

Engine Number

Serial Number

Other Data: Distributor Number, etc.

Telephone (Home) Telephone (Work)

Credit Card ($25.00 minimum)

Exp. Date

Name of Cardholder (print)

3 or 4 Digit V Code

Signature of Cardholder (Required)

PAGE QTY. PART NUMBER DESCRIPTION PRpIaCiEr //seeatch

TOTAL

C U T H ER E . . . A NEW ORDER BLANK WILL BE SENT WITH YOUR ORDER

Please Note: Personal checks are welcome. Please allow delay in shipment for bank clearance.

U.S.A. shipping and handling (48 states) please include 10% of amount in subtotal box, minimum $11.00. Outside U.S.A. 20%, minimum $25.00.

For special instructions please use the back of this form. If you need an item not covered in this catalog, please call 1-617-244-1118, or be very specific about the part(s) on the back of this form. We have over one million new and new old stock parts covering Chrysler products from 1929 to 1976 available to you.

SUBTOTAL

Mass. RES. 6.25% Tax

Core Charge Shipping & Handling

TOTAL

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