Core Submission Form
Moose Diesel Core Submission Form:
Ship to:
Moose Diesel
Core Return
3830 B Augusta Hwy
Gilbert, SC 29054
You may print this and complete it or use your own paper and include all the information here. Please PRINT neatly.
Shopify Invoice Number: ___________________________________________
First Name: _____________________________________________________
Last Name: ______________________________________________________
Shipping Address - If different from Billing Address
Street: __________________________________________________________
City: ___________________________________________________________
State: __________________________________________________________
Zip Code: _______________________________________________________
Mailing Address if not the same as shipping address
Street: __________________________________________________________
City: ___________________________________________________________
State: __________________________________________________________
Zip: ____________________________________________________________
Phone Number: ( )____________________________________________
Email Address: ___________________________________________________
Vehicle Information: Circle all that apply
Ford 6.9L 7.3L Model Year _____________ Turbo? Yes No
Chevy 6.2L 6.5L HMVW 12V 24V Type of Transmission _______________
Model Year _________