Company Name:​                                                                                                                     

Name                                                                                                                                       

Address Street​                                                                                                                        

City​                                                                                                                                         

State​                                              

Zip Code: (5 digits)                                 

Phone                                                                                   

Email​                                                                                                                                      

Year of Car                           

Make/Model of Car/Motor size                                                                                              

Build Date of Car                                                         

Assembly Date of Motor                                                        

VIN ​                                                                            

Date you want stamped on unit                                                                    

Broken Fins?                   How many?                         (Add $25/fin)

When do you need the unit?                                                

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Comments: ​                                                                                                                                                                                                                                                                                                                                                                                                                                               

​Contact Form

Please print and send this form with  your fan clutch

(​Ctrl P)

Tel: +1(813) 477-5128

481 Olive Ct., Warrensburg, MO   64093