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This form must be completely filled out. Any changes to your order must be in writing
One work order must be filled out per transmission ordered.

443 Pitts School Rd. NW   Concord, NC 28027   Tel: (704) 782-4343   Fax: (704) 782-4443 Hours: 9:00AM - 5:30PM EST Mon-Fri	P.O #:_____________
Jerico® PERFORMANCE PRODUCTS TRANSMISSION WORK ORDER
Name:	Date:
Company:	Customer #:
Address:	Serial #:
	Assembled by:
Phone: [WK]                                  [HM]                                  [FAX]
Deposit: A non-refundable $1,000.00 US dollar deposit is required in cash, cashier's check or money order

2,3, AND 4- SPEED OVAL ROAD RACE TRANSMISSIONS: Circle, check, and fill in the choices below
MAKE: Chevy   Ford   Other:	MOTOR: Big Blk.   Small Blk.	CLASS:

T R A N S	#WC4 (4 SP. TOP LOADER)     #RR4 (4-SP. TOP/BOTTOM LOADER)     LENGTH:   21-1/2   or   24-1/2 Deposit required. Order form must be completely filled out.
	#WC4-4 (NEW SUPER DUTY 4 SPEED TOP LOADER) 21-1/2 ONLY Deposit required. Order form must be completely filled out.
	#Y2K (Jerico® LIGHTWEIGHT 4 SPEED TOP LOADER) 21-1/2 ONLY Deposit required. Order form must be completely filled out.
	#2SP (2 SP. TOP LOADER) 21-1/2 ONLY         #3SP (3 SPEED TOP LOADER) 21-1/2 ONLY No deposit required. Order form must be completely filled out.
[_]       SPECIAL OPTIONS:   Aluminum Case WC4 (#ALC)   Speedometer (#SPO-W) NOTE: SPECIAL OPTIONS SOMETIMES REQUIRE EXTRA LEAD TIME, AS THEY ARE CUSTOM WORK
[_]       OPTIONAL INTEGRAL COOLING PUMP:   1 PUMP (#OT01KT-0)   DUAL PUMPS (#OT02KT-0) [_]       *FILTER:   #LF-100   *(MUST USE IF USING OUR PUMP)
[_]       OPTIONAL CAGED ROLLER BEARINGS            IN TAILHOUSING #KT-O   (Must use 1350YMW yoke with this option.)
INPUT CLUTCH SPLINE:   10 (1-3/8)   18   26   INPUT PILOTS:   FORD   CHEVY   OTHER:
BEARING RETAINER:   Cast (Standard)   Billet (Optional-#BRO)   FOR:   FORD     CHEVY                                     Billet Quarter Master (#BRO-QM)                     OTHER:
SHIFTER:     Yes   /   No         #JH500-O (H-Pattern)       #499-8777-2SPO (H-Pattern, 2 Speed)       #499-8777-3SP

[_] **SHIFT ARMS:   #SA-3SP   #SA-2SP   (**DO NOT CHECK IF ALREADY ORDERING SHIFTER, ABOVE)
[_] SHIFT KNOB #163-0003   [_] SEALANT   #90003-B (LG)   [_] SHIFTER HANDLE (#538-0015)
[_] YOKE: 1350 SERIES (1350Y) or (1350YMW)   1310 SERIES FOR 2-SPEEDS (#1310Y)
[_] U-JOINT: 1350 SERIES (#1872)   1310 SERIES FOR 2-SPEEDS (#1310Y)
[_] REAR POLYURETHANE TRANS MOUNTS (#M311)	OTHER PARTS:
Packaging and handling charges $35.00 (UPS charges additional)	(Sales Tax is six percent (6%) for North Carolina customers, and applies when picking up a transmission or parts here in Concord, NC)

Ratios Main Drive: ___/____	Do you have any special instructions for us?
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Prices and specifications are subject to change without notice. There is no warranty, stated or implied, due to the unusual stresses placed on racing parts, and because we have no control over how the parts are installed or used.