Antique Gas Stoves

P.O. Box 9507 Alta Loma CA 91701

(909) 484-2222

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)

Restore simmer cap(s)

Misc. Item(s)