**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!