1962-1979 FENDER TAG RESTORATION
                                                           INFORMATION NEEDED:
(PRINT CLEARLY OR TYPE)
Please fill in as much information as possible.

1. Owners Name: 		

	Address:		 	

	City, State & Zip: 		

	Home Phone Number:  	 Work 	

	E-Mail Address: 	
	SEND #2, 3 &4.
 2. Copy of Title or Registration-IN YOUR NAME, Bill of Sale or Legal Proof of Ownership.
 3. Pencil rubbing of Serial Number on Door Pillar (1967+Older) or Dash (1968+Newer).
 4. At least one (or more) of the following items: 
	A. Copy of original (rusty-but somewhat readable) Fender Tag(s).
	B. Copy of Broadcast Sheet and/or Original Window Sticker-prefer COLOR copy, 
	C. Original Dealer Invoice/IBM card/Order Form with Vehicle Order Number listed.

     IF YOU HAVE ANY OF ITEMS 4, GO TO #8.   IF YOU DO NOT HAVE ANY ITEMS 4 - GO TO #5.

 5. Names, Addresses & Phone Numbers of 1 (or 2) known previous owners.

						 				

						 				

 6. Copy of one of the following items:
	A. Manufacturer's Statement of Origin, (from state DMV) or
	B. Original Chrysler Invoice (From Original Selling Dealer), or
	C. Donor Fender Tag from Same Year (1969 or newer), Model & Plant. 
	(Tag will not be returned!-Example: 1969 Road Runner=any 1969 Belvedere built @ same plant)

 7. 35MM Photograph's (Or video) of the vehicle in an unrestored condition: CHECK WHEN DONE
	BODY: Eye level-Drivers Side __, RH Side __, Front __ & Rear __. Rear window area __.
	Secondary Body Code Numbers behind left rear bumper area __ (1966-67 B-Body only).
	UNDERHOOD: Complete LH __, CTR __, RH __, UPPER __, LOWER __ firewall w/Air 
	Cleaner removed __, Lower Steering Column at Firewall __, Master Cylinder __, Radiator
	Part Number __ = __________ & Diameter of opening (19"), (22"), (26") or (28"). Power 
	Steering Pump __ & Gear __. Underside of hood __, Primary Radiator Support Body Code 
	Numbers __, Secondary Cowl Body Code Numbers __ (1970-74 E-Body & 1971-74 B-Body 
	only), Idle Label __ (Found on 1968 & newer vehicles),  If S/S HEMI  RH shock tower __.
	GLASS: Windshield __, Side Windows __, Rear Window __, Get close-up of windshield 
	(bottom center) __ & side __ & rear window lettering w/date __. W/Shield is dated: ____.
	INTERIOR: Complete dash top __, gauges __ & bottom __. VIN on door pillar or dash __, 
	Dash w/speedometer & gauges __, Radio __, Front __ & rear seats __, 6-Way? __, 
	Door panels __, Headliner __, Door VIN Decal  ('69 DAYTONA only) 1970 & Newer __, 
	Tire Label __, Original body paint on passenger floor under carpet __. 
	Secondary Body Code Numbers on package tray  __ (1965 & older models, 1970-71 Duster).
	Interior complete firewall if 1962-64 MAX WEDGE or 1964-68 S/S HEMI __. 
	TRUNK: Underside of lid __, Spare Tire/Wheel __, Spare tire mounting area on '70-71 
	E-Body Original paint on rear speaker panel __, Secondary Body Code Numbers on LH 
	trunk lip under weatherstrip __(1968-70 B-Body, 1970-71 Dart), Bumper Jack Assy __, 
	Battery mounting area if MAX WEDGE or S/S HEMI __.




 
	CHASSIS: Bottom of K-Frame __, '70 & newer coin # on K-frame __, Front brakes __ & 
	diameter- 9", 10" or 11" (Circle one), rear brakes __ & drum diameter- 9", 10" or 11". 
	FT & RR Shock Numbers: 	 	 (Optional), 
	LH & RH Leaf Spring Numbers: 	 	, 	Sure Grip?
	8 3/4" 3rd Member Casting Number:  2070741,  2070742,  2881489  (LH Side of carrier),
	Rear axle tube-front __, and rear __, Axle Ratio tag __, Chassis-rear of front tires __, 
	Front of rear spring mounting area __,  Rear of rear spring mounting area __,  
	Frame and body above axle assembly__. (Rubber Bumpers & pinion snubber)
	Every square inch of underbody if MAX WEDGE or S/S HEMI-including wheel wells __,
	and Parking Brake Cables.

8. Return this inquiry with amount due: call if prices are not circled below! (A, B or C + S&H=Total)

A. Fender Tag Assembly/If you have a rusty Fender Tag.	                                               $  110.00
	OR
B. Fender Tag Assembly/If you have a readable Broadcast sheet. (Decoding incl.)	$  165.00
	

	OR
	Plus the next items if needed---Check with GTS first. 	 PLUS
	For  2nd TAG (IE: Well optioned car,  TRANS AM,  HEMI FENDER,  etc). Add	$    60.00
	Plus DONOR TAG (See 6C) 1969 & newer only -if needed	$    50.00
	Plus FENDER TAG SCREWS  (Used pair - if needed) 	$    10.00

	All US orders are shipped to customer via 3 day-Federal Express  S&H=	$    16.00
        International or Canada Orders shipped Registered US Mail 			$    22.00

	RUSH FEE/2 WEEK TURNAROUND TIME  	                                                $    75.00
	Total   =	$ 	 
	
“CORRECT” FENDER TAG (s) WILL BE IN STEEL AND ARE EXACT REPLICAS OF THE ORIGINAL.

	All orders checked for accuracy & authenticity. VIN:  	.
	Body Codes found on Radiator Support:  		.

	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)	11/05/2007