Advanced Injector
220 North Dexter
Valley Center, Kansas, 67147

Name _____________________________________________________________ Date   _______________

Shipping Address  ________________________________________________________________________

City _______________________________________ State_________  Zip Code______________________

Phone  ___________________________                    Email    _____________________________________

                                                  VEHICLE / INJECTOR INFORMATION

 Year & Make of Vehicle __________________________  Model ___________________________________    

    TOTAL NUMBER OF INJECTORS ENCLOSED __________ SERVICE REQUESTED  (circle one)

Clean & Flow  ($14 ea)             Flow test only ( $10.00 ea)            Install hoses ($5 ea)

Other, specify below

Additional information or special instructions:

PAYMENT METHOD    MC                 Visa                    PayPal              Money Order

Acct #________________________________________________        Exp. Date  ____________________

Full name as it appears on Card ____________________________________________________________

Billing Address  __________________________________________________________________________
(if different than shipping  address)

City_______________________________________  State ________  Zip Code ______________________

I agree to pay according to card issue agreement:______________________________________________
(Must be signed for credit cards)                                     Signature

 $10.00 flat rate for return shipping by priority mail that includes $100 insurance. If additional insurance is required, add $1.25 per $100 additional insurance, up to a maximum insurance of $500. Please wrap your injectors separately and place in a plastic bag before shipping. Prices subject to change without notice. (Revised 05/19/2012).