Name:    
Date:      
Email Address:
Address:
Residential Business
City:        State:
Zip:
Telephone:
    Work: Home:

Type of Racing:
Class: Year:
Vehicle Type:
Engine Size: Bore: Stroke:
Heads:     Manifold:      
Carb:
Cam:     Hyd: Flat Tapper: Roller:    Centerline:
Adv. Lift & Duration:
@.050
Vehicle Weight W/ Driver:   
Rear End Gear Ratio:
Transmission Type: Year:
Lock Up: Yes: No:
Input Spline Count: Tire Size:
Converter Size: 8" 9 " 10" 11" 12" 13"   Other:
Desired Stall Ratio:
New Build Rebuild
Motor Plate:
Part #

Notes:

Special Instructions:

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Card#
Card Type: MasterCard Visa Discover American Express
Expiration Date (MM/YY):
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If Yes:

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