(This form must be completed a shipped back with core to receive refund)


This form will be included in the shipment with your new supercharger!


Name:______________________     Company_______________________

Address:________________________________________________________   

City:_____________________   State:____________   Zip:____________

Phone:__________________________  Fax:____________________( optional)

Vehicle Information

Manufacturer:____________________   Model:___________________________

Year:________  Engine:_____________  Mileage:_________________________


Complaint: Reason for replacement

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________



26988 SE Hwy 19   Unit 47
PO Box 186
   Old Town,  FL  32680
352-542-0147
         352-542-9468 (Fax)


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