For a printer-friendly version of this order form, please click here.
Name (required):
Email:
Home Phone (required):() -
Work Phone:() - Ext.
Fax:() -
Street Address (required)
(UPS will not deliver to P.O. Boxes):
Line 1:
Line 2:
City (required):
State (required): Zip (required):
Car Year:
Car Make:
Car Model:
Distributor Make:
Distributor Model:
Distributor Model ID #:
Engine Make (if avail.):
Engine Year (required):
Engine Displacement:
Type/No. of Cylinders:
Electrical: 6 volt 12 volt Neg. Ground Pos. Ground
Work to be done:
To prove you are human and not a spam robot, please enter the second set of numbers and letters exactly as they are listed above (required):
To sign off on the work order, please type in your signature here (required):
Notes:
Parts/materials shipped with the unit to be re-built:
Should Buffalo Machine Works supply New Silicone Heat Treated Cap and Rotor?
YesNo
Δ