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 bold faced type is required. Other info helpful if available.

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)