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55727 Twentynine Palms Highway Yucca Valley, California 92284 http://www.oldtownyucca.com/coleman
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Name: ___________________________ Address: ____________________ City State Zip: ________________ Daytime Tel: ______________________ Email: ____________________________ Contact Preference: Phone or Email (circle one) |
Manufacturer: _________________________ Type (stove, lantern, ect.): ______________________ Model: ______________________________ Date Mfg: _____________________________ Items supplied: _______________________ |
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Services Requested Item Rebuild Frame Painting Fuel Cap Machine Buffing |
Description Includes cleaning, parts and testing Paint (or) Leave bare metal (see note 1, below) Repair original and include replacment. (see note 2, below) Nickel Plated Founts and Tanks only (see note 3, below) |
Charge $55.00 None $5.00 $10.00 |
Amount Due _______.__ _______.__ _______.__ _______.__ |
Additional Parts Order:
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Quan |
Part Number | Description | Unit Price | Amount Due |
| Subtotal | ||
| California residents please add 7.25% sales tax for any additional parts ordered. (x.0725) | Sales Tax | |
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Contiguous US: 2 or 3 Burner Stove $25 / Lantern: $15 Alaska & Hawaii: 2 or 3 burner stove $25 / Lantern: $15 International surface: 2 or 3 burner stove $45.00 / Lantern: $35 Lamp Shades Add: $10 Contiguous US, $12 Alaska & Hawaii and $28 International surface |
S&H | |
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Visa / Mastercard / AmEx / Check Enclosed (circle one) Card Number: ___________________________________ Expiration Date: _______________________________ Name on card: __________________________________ Signature: _____________________________________ |
I hereby authorize the above repair work to be done along with necessary materials. I understand and agree that the repair facility is not responsible for damage to the item(s) during shipment or return shipment. I acknowledge that a replacement fuel cap is an important safety concern and I release the repair facility from all liability if the original fuel cap is repaired and returned. I understand that I am solely responsible for the safe storage and operation of this equipment. Additionally, I release the repair facility from all responsibility that for any damage or injury that may occur from the handling, storage or use of any repaired or replaced item. Signature: ________________________________________ |