Antique Gas Stoves

P.O. Box 3175 Montclair CA 91763

(909) 445-0300

NAME_____________________________________________________

ADDRESS__________________________________________________

CITY__________________________STATE________ZIP___________

TELEPHONE________________________________________________

EMAIL ADDRESS____________________________________________

Check what parts or part you are sending and quantities:

Ring

Inter Ring

Other

Name Brand of stove_________________________________________________________________________________

Model & Serial Number _____________________________________________________________________________________