Core Submission Form

Moose Diesel Core Submission Form:

Ship to:

Moose Diesel
Core Return
3830 B Augusta Hwy
Gilbert, SC 29054

Write CORE RETURN on the outside of the box. 

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 _______________ 

Other Make ___________________Model ___________________

Model Year _______________