Impala SS - Certificate of Registration

Impala SS REGISTRY © - All Rights Reserved
Credit Cards accepted are Visa, MasterCard, American Express, and Discover.

Note: The information entered is not checked for validity - please make sure card number/ccv is entered correctly.

 

Your email address for receipt confirmation
(youremail@yourhost.com)

Your order will be processed without a valid email address but you will not receive a confirmation receipt from the Impala SS Registry.
   
Select your purchase (Check One)
 Standard Certificate - U.S. Mailing Address - $28.95
 Standard Certificate - Canada Mailing Address - $43.95
 Custom Certificate - U.S. Mailing Address - $33.95
 Custom Certificate - Canada Mailing Address - $48.95

   
Frame Color
 Gold
 Blue
 Green
  Maroon
 Red
   
Add $9.00 for U.S. Priority Mail ?  Yes - add $9.00 for U.S. Priority Mail
 No - Do not add $9.00 for U.S. Priority Mail
   
VIN of the Impala SS 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)
   
Phone Number (optional)
   

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)