Antique Gas Stoves

P.O.Box 9507 Alta Loma CA 91701

(909) 484-2222

Core Refund Form

NAME_____________________________________________________

ADDRESS__________________________________________________

CITY__________________________STATE________ZIP___________

TELEPHONE________________________________________________

EMAIL ADDRESS____________________________________________

NAME BRAND OF STOVE______________________________________


quan....description                  Invoice number
_____| Thermostat with knob          _______________                           
_____| Thermostat                    _______________                   
_____| Safety Magnet Valve           _______________