**AMPHICAR.NET UNIVERSAL PARTS LIST QUESTIONNAIRE**
Mail completed forms to: Bill Connelly, 8389 Luce Court, Springfield, VA 22153 
 
PLEASE PROVIDE THE FOLLOWING CONTACT INFORMATION:
 
Your Name:

Your E-mail (if any):
 
Website (if any):
 
WHAT ORIGINAL AMPHICAR PART CAN THE ITEM BE USED FOR?
 
Amphicar Part Name:
   
Model, type or other designations:
   
Amphicar Part Number:
 
WHAT IS THE REPLACEMENT OR SUBSTITUTION PART OR ITEM?
 
Product Name or Maker:

Model, type or other designations:

Product Code or Part Number:
 
WHAT IS THE MANUFACTURER OR OTHER SOURCE FOR THIS PART?
 
Manufacturer or other source:

Street Address:   

City:

State/Province/Country:

Zip or Postal Code:

Email/Internet site:

PLEASE CHOOSE ONE OF THE FOLLOWING:
 
I have actually used this part  (  )
I have NOT used this part       (  )
 
WHAT IS THE COST OF THIS PART?
 
$ ________

IF GORDON IMPORTS SELLS THIS OR AN EQUIVALENT PART, HOW MUCH IS IT?
 
$ ________

PLEASE DESCRIBE BELOW OR ON THE BACK OF THIS FORM ANY MODIFICATIONS NECESSARY

TO MAKE THIS PART FUNCTION CORRECTLY, TOGETHER WITH ANY ADDITIONAL COMMENTS,

INFORMATION OR PHOTOGRAPHS.  Thanx!  

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