1 - Dirt-Tech



1. Ordered By:

|Name: | |

|Company Name: | |

|Mailing Address: | |

|Address (cont.): | |

|City: | |

|State/Providence: | |

|Zip/Postal Code: | |

|Country: | |

|Daytime Phone: |( ) - ext: |

|Fax: |( ) - |

|E-mail: | |

2. Payment Type:

Check COD Pre-Pay

3. Ordered for:

|Name: | |

|Company: | |

|P.O. # | |

4. Ship to Address: (leave blank if same as Ordered By:)

|Street Address: | |

|Address (cont.) | |

|City: | |

|State/Providence | |

|Zip/Postal Code | |

|Country: | |

5. Quantity:________________

6. Distance from tube-end To tube-end:________________

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7. Lower Trailing Arm Bracket Centerline:__________________

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*LOWER BRACKETS ARE 3in INSIDE WIDTH*

8. Circle for: Back Bracing Yes No

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9. Circle for: Upper Four-Link Brackets Yes No

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*UPPER FOUR LINK BRACKETS ARE 2in INSIDE WIDTH*

--Will accept up to a 1 ¼in Heim--

10. Upper Truss Yes No

If yes: Full length Half length (half length shown)

11. Tube Size 4 inches 3.5 inches

*Filler Bung Size is 2in and location is standard*

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12. Circle Vent Location / Size:

Ship Loose AN -6 AN -8

Standard Location AN -6 AN -8

*Housings are sold without Hub assemblies, unless other wise requested. Fully assembled rear-ends are available*

Custom Applications will be subject to additional Charges and Rates

Dirt-Tech will not be held responsible for any information NOT provided on order sheet, if there are special instructions, please call to verify.

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