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 _________