First Name or if shipping to Business: ________________________________________Date ____________

Last Name:_________________________________________________________________



State (print out):_________________________________ Zip Code:_____________

Phone number:____________________________________________

Email Address:____________________________________________

Shipping Address: Business____ (OR) Residential____

Vehicle Make:________________________ Year_________

Engine Size________ Carburetor Type: (If Known)_______________

Contact if extra minor work is needed:______ Contact only if extra work would exceed:$_________

Shipping Insurance (recommended :Y____) (Default:N____) UPS charge app. $1.00 per $ 100.00 Merchant is not be responsible for lost or damaged packages . We advise you to purchase shipping insurance.

We are not responsible for any packages left outside our business while business is closed.Packages can be stolen or miss delivered.. Make sure you request a signature for your packages shipped to us.

Release with out signiture:(Y____) (Default:N____)

Amount of insurance coverage $______ (Default $500.00)

Warranty: 6 month____ Lifetime____

Since 1944
Custom Rebuilding and Restoring
Carburetor USA
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