Please fill out this form as completely as possible when submitting items for restoration.

Full name: ____________________________________________________________________

Company: ____________________________________________________________________

Address: _____________________________________________________________________

Address 2: ____________________________________________________________________

City: __________________________________

State/Province: ____________________

ZIP/Postal Code: ___________________

Country: __________________________

Home phone #: _________________________________________

Work phone #: _________________________________________

Fax #: ________________________________________________

E-mail: ______________________________________________________________________

Web site: _____________________________________________________________________

My vehicle is a:

___Car ___Truck Other (please specify): _________________________

Year: 19___

Make: ________________________________________________________________________

Model/Series: __________________________________________________________________

With:

Engine: ______________, ______cu. in.

Transmission: ___Standard, ___speed

___Automatic

Air conditioning: ___Yes ___No

COMMENTS/SPECIAL INSTRUCTIONS (use back of sheet if necessary):______________

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