Max Power Inc.
3001 Progress Rd.
Madison, Wi. 53716
Please
print this form, complete and include with your
cylinders.
NAME:
PH.#
ADDRESS:
E-MAIL:
DATE SENT:
DATE NEEDED:
BIKE
INFORMATION:
MAKE:
MODEL:
YEAR:
Please supply me with the services and or
parts specified below:
TOP
END BEARING
CYLINDER
EXPRESS
ADDITIONAL PISTONS
BIG
BORE KIT:
When sending your cylinder for a Big Bore
kit, please make sure to include your cylinder,
head and power valve all in tact. We will re-install
before delivery.
OTHER
INFORMATION: (please provide as much information about
your jetting,
gearing, and aftermarket add ons - such as pipes,
silencers, reed cages etc.)
PAYMENT METHOD:
We can return your Cylinder & or Parts UPS
COD Money Order / Cashier check only. Or we accept
Visa, Mastercard, Discover or American Express Cards.
I
would like to pay with: (please check one)
PERSONAL
MONEY ORDER
VISA
(Please
enter your card
details and sign below)
MASTERCARD
DISCOVER
AMERICAN
EXPRESS
Cardholder's
Name:
Card
Number:
3 digit CVV code
(4 digit American Express)
Expiration
Date:
I authorize Max Power Inc. to charge for
services received:
Cardholders Signature:
Please remove below
label and adhere to box when shipping (cover with
clear tape)
