International Chevelle/Camaro/Nova L78 Registry - Certificate of Registration

L78 REGISTRY  - All Rights Reserved
Credit Cards accepted are Visa, Mastercard, American Express, and Discover.

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(youremail@yourhost.com)

Your order will be processed without a valid  email address but you will not receive a confirmation receipt from the L78 REGISTRY.
   
Select your purchase (Check One)
 Standard Certificate - U.S. Mailing Address - $26.00
 Standard Certificate - Canada Mailing Address - $29.00
 Custom Certificate - U.S. Mailing Address - $31.00
 Custom Certificate - Canada Mailing Address - $34.00

   
Frame Clolor
 Gold
 Blue
 Green
 Red
   
VIN of the L78 for confirmation
   
Name(s) to appear on certificate
(Exact spelling and capitalization)
   
Ship to Address (1)
   
Ship to Address (2) (if needed)
   
Ship to City
   
Ship to State/Province
   
Ship to ZIP/Postal code
(xxxxx), (xxxxx-xxxx), (xxx xxx)
   

Card Information

 
Card Type (Check One)
 VISA
 MASTERCARD
 AMERICAN EXPRESS
 DISCOVER

   
Card Number
(xxxx-xxxx-xxxx-xxxx) or (xxxxxxxxxxxxxxxx)
   
CCV Code on back of card
(xxx)
   
Expiration Date (mm/yy) (xx/xx)
   
Billing ZIP/Postal code of cardholder
(xxxxx), (xxxxx-xxxx), (xxx xxx)
   
   
Add Toolbox Magnet?
L78 REGISTRY Magnet
 Yes Please - With Standard Certificate $5.00
 Yes Please - With Custom Certificate $4.00
 No Thank You - $0.00