Buffalo Machine Works                Assigned Work Order # ___________

PO Box 187 or 18073 Jefferson County Hwy 126                                            supplied by Buffalo Machine Works

Buffalo Creek, CO  80425

303-838-0372, toll free 888-895-9904 (fax) 303-838-5709

 

Info in red (or bold face type) is required. Other info needed if available.

Required info must be included with your distributor.

 

Customer name:    ______________________________________________________  

 

Phone (W):  _________________________   or (H) ____________________________   

 

Fax: ___________________    Contact: ______________________________________

 

Street address (UPS will not deliver to P.O. Boxes): __________________________

    

City: ______________________   State: ____    Zip: _________

 

Distributor make: _____________________     Model #: _________________

 

 

Vehicle make: ________________    Model: ________________________   Year: ___

 

Engine make: __________________ Type / # of cylinders: __________  Displ: _______    

 

Work to be done:  _______________________________________________________

 

 _____________________________________________________________________

 

Method of payment: (cash, check, credit card, debit card, money order)

 

(circle one)   MasterCard ---- Discover ---- Visa

 

Card #  _  _  _  _  -  _  _  _  _  -  _  _  _  _  -  _  _  _  _       Exp. Date: _____ - _____

 

 

Signature: ____________________________________________________________

 

 

Notes:  ________________________________________________________________

 

 _______________________________________________________________________

 

 

Parts/materials shipped with the unit to be re-built:  ________________________________

 

 ______________________________________________________________________

 

Should Buffalo Machine Works supply New Silicone Heat Treated Cap and Rotor?

Yes   No   (please circle one)