Order Form

6728 San Fernando Road
Glendale, CA 91201

Order Line (800) 898-8684	Info Line (818) 500-8778
Fax Line (818) 500-8777	E-Mail: OnlineOrders@vintagepartsinc.com

Name:	Phone:
Address:	City:
State:      Zip/Postal Code:      Country:
Vehicle Information:
Qty Part Number Description (Include Color) Unit Price Total Price Paymnet - We accept: Visa, MasterCard, Discover, American Express, Check, or Money Order Account Number:   Expiration Date: mm/yy   Name on Card:   Signature: ______________________________ SubTotal:   Sales Tax (CA Residents 7.75%):     LA County Residents 8.25%):   Shipping 10% ($5.00 min.):   Total:
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