RESTORATiON   Restorations
Corvette Specialties of MD West
75100 St. Charles Place Suite A
Palm Desert, CA  92211
PARTS SUBMiSSiON FORM

COMPLETE and PRINT this form from your browser window and include it with your parts.
***Please read carefully and fill in all applicable areas. Your jobs will be delayed if form is incomplete.***

Shipping Information

First Name:   Last Name:

Company name:

Address Line 1:

Address Line 2:

City:  State:  Zip Code:

Primary Phone:  Secondary Phone:  Please be sure to include a contact # as we may need to call you.

Email Address:
Corvette Specialties of MD West will NEVER give away or sell your email address to ANYONE.

Payment Info:
(place an X in the appropriate boxes below)		 Please note:  DO NOT send payment with items.
If complete Credit Card information is not provided, parts will be shipped COD.
COD All Cash-On-Delivery orders are payable by money order or cashier's check unless prior arrangements are made.
NO cash or personal checks will be accepted.  Additional UPS fees apply.
Credit Card
Please Note: For your security, this form
DOES NOT submit your Credit Card
information electronically.  		Visa MasterCard  Discover
Card Number:   Expiration Date (MM/YY):
Security Code from the back of the Card (REQUIRED):
Name exactly as it appears on the Card:
Billing Address if different from address above:
Address Line 1:
Address Line 2:
City:  State:  Zip Code:

Vehicle Information

Year:     Horsepower:      Interior Color:  (Specify if sending 58-62 dash clusters, 64-67 consoles, etc.)
Place an X here if the car will be judged at NCRS or Bloomington type events.

Items Enclosed

Enter the quantity of each part you are sending in the boxes below:

Dash Cluster Assy. Including Gauges (leave key in ignition OR remove ignition before shipping. $15.00 charge to remove ignition cylinder if key is not provided)
                          Place an X here if you would like the odometer reset to zero if it is replaced.
Tachometer (If including 53-61 unit, please specify drive type:  Distributor Drive Generator Drive
Speedometer            Place an X here if you would like the odometer reset to zero if it is replaced.
Gauges:   Fuel Temp Battery Oil  (Please DO NOT remove gauges from 53-62 case models)
Clocks 63-82:  Standard Movement  Quartz Moverment  (53-62 owners, we perform cosmetics ONLY, no mechanical repairs)
Console
Glove Box Door   Glove Box Assembly
Dash Insert 58-62
Headlight Motor
Wiper Motor:  Type I Service   Type II Service   Type III Service
Other: 
 Place an X here if unit is a REPAIR ONLY - NO COSMETICS
Applies to individual gauges only (part of a cluster).  Remember, we can make your parts look New!
Please list all other commments, instructions, or requests here.  Be as specific as possible.  For example: red line changes, additional services, etc.

Corvette Specialties of MD West will make every effort to notify the customer should unexpected or unusual situations arise that cause a substantial overage in your Service Fee.
Please remember we are working on items that are often 40 or more years old and are normally meant to be replaced when failure occurs.

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