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: ______________________________

Sales Tax (CA Residents 7.75%):  

  LA County Residents 8.25%):  

Shipping 10% ($5.00 min.):  

Print Out and FAX this Completed Form and
Fax To: (818) 500-8777

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