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:………………………………………………..

Guidelines provided by NZ Customs
Declared value for Customs purposes-
Guidelines provided by Customs confirm that unless the damage is insignificant the value of cylinder/s requiring repair will generally be the scrap metal content value. Please declare the value of your cylinder/s appropriately. You may be able to insure them for more if this is necessary. Call us toll free if you have any concerns. ph 1800 724 166

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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