PDF 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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