| DATE:__________________________
CUSTOMER # ______________________ NAME: ______________________________________________________________ ADDRESS:___________________________________________________________ CITY: _________________________________ STATE: _________ ZIP: __________ PHONE: ____________________ CONTACT PERSON: _______________________ |
|
TERMS: COD ___ MONEY
ORDER___ MASTER CARD ____ VISA ____
CREDIT CARD #
___________________________________ EXP. DATE: ________
** if credit card # is not completed, your order will be shipped COD/Money order. Indicate if you want Midway Machine to call for card number before shipping. |
| MAKE: ______________ MODEL:
_____________________YEAR: ________ |
|
SERVICE REQUESTED: check
appropriate services
PLEASE SUPPLY us with the PISTON
TO
CYLINDER CLEARANCEHONE:
______
FIT with WISECO PISTON: ______
BORE: _____ FIT with OEM type PISTON: _____ FIT with other after market PISTON: _______ RESLEEVE: _____ USE PARTS SUPPLIED: _______ REBUILD CRANKSHAFT: _____ If you supply the piston __________________________in. OR _____________________________ mm |
| PARTS NEEDED: check appropriate
parts PISTON: ___ RINGS: ____
WRIST PIN: ____
WRIST PIN BEARINGS: ______GASKET KIT: ____ BEARINGS:_____ We will use Wiseco pistons, rings, wrist pins, and bearings. |
| COMMENTS:
___________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ |