Name:...............................................................................................................................................................................................
Company:..........................................................................................................................................................................................
Date:.................................................................................................................................................................................................
Address:...........................................................................................................................................................................................
City/Town:..............................................................................Postcode...........................................................................................
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:.....................................................................................................................................................................................
.....................................................................................................................................................................................................
.....................................................................................................................................................................................................
.....................................................................................................................................................................................................
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: ................................................................................................................
ADDRESS LABEL FOR YOUR USE
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NZ Cylinders
210 Wills Street
Ashburton 7700
New Zealand
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------