Please print out and complete this form. Pack this with your cylinder and send to the address at the bottom of this page. Alternative versions .PDF file or mobile version

Please value your cylinder/s at a scrap metal value; you may be able to insure them for more if this is nescessary. Feel free to ring us toll free

1 800 724 166 if you have any concerns.

Address/Contact Details

Name:...............................................................................................................................................................................................

Company:..........................................................................................................................................................................................

Date:.................................................................................................................................................................................................

Address:...........................................................................................................................................................................................

City/Town:.........................................................................................................................................................................................

Phone:....................................................................................

Email:.....................................................................................

Cylinder Information (Please remove studs, powervalves, and fittings)

Make and Model:.......................................................................................................................................................................

Year:.........................................................Engine Number........................................................................

We require piston is it included: Yes / No..............................................................................................................................

If NO do you want us to supply one: Yes / No......................................................................................................................

We require all studs, power valves etc to be removed. There will be an extra charge if you would like us to do this.

We will repair and/or replate your cylinder/s, do you have any special instructions for this cylinder: Yes / No

Describe:.....................................................................................................................................................................................

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Payment Method:- Visa / Mastercard (We will advise on pricing before payment is put thru)

Credit Card(Circle one)- Visa -- Mastercard

Card # .......................................................................................................................................

Exp. Date ..................................................................................................................................

Card Holders Name: ................................................................................................................

Direct Debit Account: Y / N

Westpac Account Details -- D G Engine Services Ltd : 030835 0252003 00

 

 

 

 

 

 

 

 

 

ADDRESS LABEL FOR YOUR USE

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NZ Cylinders

210 Wills Street

Ashburton 7700

New Zealand

NZ Customs :- Contains used engine parts; temporary import for repair & return.

 

 

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