Please
print this form, complete and include with your
cylinders.
NAME:
TEL:
ADDRESS:
POSTCODE:
E-MAIL:
DATE SENT:
DATE NEEDED:
BIKE
INFORMATION:
MAKE:
MODEL:
YEAR:
Please supply me with the services and or
parts specified below:
MAX POWER HAT(s)
Quantity
.............
Color Blue
Color Black
TOP
END BEARING
CYLINDER
EXPRESS
BIG
BORE KIT:
STAGE
ONE
STAGE
TWO
STAGE
THREE
STAGE
FOUR
STAGE
FIVE
When sending your cylinder for a Big Bore
kit, please make sure to include your cylinder,
head and power valve all in tact. We will re-install
before delivery.
Signature:
Print:
Date:
OTHER
INFORMATION: (please provide as much information about
your jetting,
gearing, and aftermarket add ons - such as pipes,
silencers, reed cages etc.)
PAYMENT METHOD:
On receipt of your cylinder or parts we will send you a proforma invoice. We accept payment by Visa (by phone or email) or by cheque (4 day clearance).
I
would like to pay with: (please check one)
VISA
(Please
enter your card
details and sign below)
CHEQUE
Cardholder's
Name:
Card
Number:
Expiration
Date:
3-Digit Security Code:
I authorize Aptec Ltd to charge for
services received:
Cardholders Signature:
Please remove below
label and adhere to box when shipping (cover with
clear tape)
