Please print this form, complete and include with your cylinders

Name:______________________________________  Home Phone #:_________________
                                                         
                                                                                         Work Phone#:__________________

Address:____________________________________  E-Mail:________________________

____________________________________________

____________________________________________  Date Sent:_______________


             Bike Information:

                Make:__________________ Model:________________ Year:_________________



                Please Supply me with the services and or parts specified below:


             Cylinder Boring & Honing              Carbide Bore Process to cast iron liner       

             Install new sleeve                            Piston Kit   

             Replate Nikasil cylinder                 Top end Gaskets      

             Head Work                                      Valve Job    

             Piston coatings                               Bead blast cylinder or head    
            

                                            Custom or Special Work. Provide instructions below:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________
                       
  

  Signature:______________________     Date:___________  
                              

                                                     

       

           PAYMENT METHOD:
           We can return your cylinder and/or Parts UPS, COD, 
           Money Order/Cashier check only. We also accept Visa and Mastercard.


         I would like to pay with: (Please check one)

                                   PERSONAL MONEY ORDER       

                                   VISA        
                                                         
                                   MASTERCARD       
                                  (Please complete your card information and sign below)



                                 Cardholder's Name:_______________________________

                         Card # :_______________________________

                                         Expiration Date:_______________________________





                             I authorize Bore Tech to charge for 
                       services received.

                            Cardholder's Signature: _______________________

Please remove below label and adhere to box when shipping
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SHIP TO:
Bore Tech
5977 Hutchinson Rd.
Batavia, OH. 45103
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