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OEM TAKE OUT SEATS

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Please Print, Fill In, and Mail
This Form to:

Discount Van-Truck
1000 South Euclid Street
La Habra, CA 90631

Business Name
Contact Name
Street Address
City,State,Zip
Phone
Fax
e-mail
Purchase Order
Check Number

Quantity	Stock #	Destiption	Price	Item Total

Please call 800/414-0485
for shipping & handling
tax amout (if any).

Total Net
Tax (if any)
Shipping & Handling
Total