packing form

First Name: ________________________________________Date __________________

Last Name:_________________________________________________________________

Address:___________________________________________________________________

City:__________________________________________

State (print out):_________________________________ Zip Code:_____________

Phone number:__________________________________

Email Address:____________________________________________ Request Tracking # ___

Shipping Address: Business____ (OR) Residential____

Vehicle Type:____________________ 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. $0.90 per $ 100.00 Merchant is not be responsible for lost or damaged packages . We advise you to purchase shipping insurance.

Amount of insurance coverage $______ (Default $500.00)

Warranty: 6 month____ Lifetime____

Comments: