Please print out and complete.  Pack this with your cylinder and send to:
NZ Cylinders, 210 Wills Street, Ashburton, 7700 New Zealand

Address/Contact Details
Name:   ........................................................................................................................................
Company:.....................................................................................................................................
Date:      ........................................................................................................................................
Postal Address:.............................................................................................................................
City/Town:.....................................................................................................................................
Phone:……………………………………………… Fax:………………………………………….
Email:………………………………………………..

Cylinder Information (Please remove studs, powervalves, and fittings)
Make:    ........................................................... Model:.................................................................     
Year:      ...............    Frame number………
We require piston is it included:  Yes / No
If No do you want us to supply one:  Yes / No
We require all studs, power valves etc to be removed. There will be an extra charge if you would like us to do this.
Any special instructions for this cylinder:  Yes / No
Describe: ......................................................................................................................................
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Payment Method
Credit Card (Circle One):       Visa       MasterCard
Card #:..........................................................................................................................................
Exp. Date:................................................   
Card Holders Name:.....................................................................................................................
(Will advise on pricing before payment is made)
Direct Debit Account:  Y / N
Westpac
DG ENGINE SERVICES
030835  0252003  00

Address Label For Your Use

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NZ Cylinders   
210 Wills Street
Ashburton 7700

New Zealand

Sender:..........................................................................
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