Name _____________________________________________________________ Date _______________ Shipping Address
________________________________________________________________________ Phone ___________________________ Email _____________________________________ VEHICLE / INJECTOR INFORMATION Year & Make of Vehicle __________________________ Model ___________________________________ TOTAL NUMBER OF INJECTORS ENCLOSED __________ SERVICE REQUESTED (circle one) Clean & Flow ($23 ea) Flow test only ( $10.00 ea) Install hoses ($5 ea) Expedited service ($25) Other, specify below Additional information or special instructions:
PAYMENT METHOD MC Visa PayPal Money Order Acct #________________________________________________ Exp. Date ____________________ Full name as it appears on Card ____________________________________________________________ Billing Address
__________________________________________________________________________ City_______________________________________ State ________ Zip Code ______________________ I agree to pay according to card issue
agreement:______________________________________________ $12.00 flat rate for return shipping by priority mail that includes $50 insurance. . Please wrap your injectors separately and place in a plastic bag before shipping. |