Antique Gas Stoves (909) 445-0300

P.O. Box 3175 Montclair CA 91763

NAME_____________________________________________________

ADDRESS__________________________________________________

CITY__________________________STATE________ZIP___________

TELEPHONE________________________________________________

EMAIL ADDRESS____________________________________________

Check what parts or part you are sending and quantities:

Oven thermostat (Please include knob)

Safety valve(s) (Please include thermocouple)

Clock

Timer

Burner valve(s)

Other

Name Brand of stove________________________________________________________________________________________

Model & Serial Number _____________________________________________________________________________________

Description of problem with stove and or part______________________________________________________________________________________________________

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