1966-1968 REPRODUCTION CERTICARD
                                                         Please fill in as much information as possible.
(PRINT CLEARLY OR TYPE)

 1. Current Owners Name:  	

    Address:  	

    City, State & Zip:  	

    Evening Phone Number:  	 Date:  	  
    Email address:  		
 2. Send a readable copy of title, registration, bill of sale or proof of ownership.
 3. Pencil rubbing of Serial Number on Door Pillar (1966-67) or Dash (1968+Newer).
 4. Readable pencil rubbing of Fender Tag, next to written fender tag info.
 5. In addition, any one of the following items: 
	A. Photocopy of Broadcast Sheet and/or Original Window Sticker,

6. Original Owners Name:  	

    Original Address: 								

    City, State & Zip: 								

    Actual or approximate Delivery Date:  	

Vehicle Identification Number:  	

7. Return this inquiry with $ 180. plus $15.00 Shipping & Handling. (U.S. only).

All Canada & International orders require $20.00- Shipping & Handling.
        WE WILL NOT BE RESPONSIBLE FOR LOST OR DAMAGED MAIL.

Note: Unless a copy of the original is provided, we are not responsible for changes for new information that is found after we have completed the initial order, you will be charged for another.

CHECK, M/O or CREDIT CARD #  	 Exp. Date  	
	
NAME ON CREDIT CARD 	 


Galen’s Tag Service, LLC. 
Galen V. Govier
37260 Sand Burr Lane
Prairie du Chien, WI 53821-8869
(608) 326-6346 VOX
(608) 326-8061 FAX
www.gvgovier.com
gvgovier@mhtc.net



Thank You		        (Please return this form to G.T.S with order)	            	          01/01/2005