Antique Gas Stoves (909) 445-0300

P.O. Box 3175 Montclair CA 91763

Any order $100.00 or more

shipping back to you is FREE

NAME_____________________________________________________

ADDRESS__________________________________________________

CITY__________________________STATE________ZIP___________

TELEPHONE________________________________________________

EMAIL ADDRESS____________________________________________

Name Brand of stove______________________________________

Check what parts or part you are sending and quantities:

Burner Head(s)

Burner Grate(s)

Stove Top(s)

Door(s)

Side Panel(s)

Control Panel

Kick Plate

Back Splash

Clock Housing

Other