FREE CATALOG REQUEST FORM
3201 S. STANDARD AVENUE, SANTA ANA, CA 92705 · www.danchuk.com
Orders (800) 648-9554 · Inquiries (714) 751-1957 · FAX (714) 850-1957
PLEASE COMPLETE THIS FORM AND CLICK SUBMIT AT THE BOTTOM OF THE PAGE TO RECEIVE YOUR FREE CATALOG. FOR FASTER DELIVERY, DOMESTIC ONLY CUSTOMERS MAY USE PRIORITY MAIL (2-3days) FOR A $6.00 CHARGE. PLEASE CALL THE NUMBER ABOVE TO USE THIS SHIPPING METHOD. ALL INTERNATIONAL REQUESTS USE DHL MAIL.
CUSTOMER INFORMATION
Customer Number:
Bill To:
Ship To:
Street Address:
Street Address:
City:
City:
State:
State:
Zip:
Zip:
Country:
Country:
Phone Number:
Phone Number:
Email Address:
Email Address:
AUTOMOBILE INFORMATION
Year:
n/a
1955
1956
1957
Model::
n/a
Bel Air
210
150
Body:
n/a
Hardtop (No Post)
Sedan (With Post)
Sedan Delivery
Convertible
Nomad
Station Wagon
Doors:
n/a
2 Door
4 Door