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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

DR4 - DRAG RACING TRANSMISSIONS:   Circle, check, and fill in the choices below
MAKE: Chevy   Ford   Mopar   AMC   Other:	MOTOR: Big Blk.                        Small Blk.	CU. IN:
TRANS:     #DR4     #DR4-4     #CL4     OTHER:	CLASS:	WEIGHT:
OPTIONS:   Road Race Sliders (#RRS)     Speedometer (#SPO-D)     Adapter (#ADP) for   Mazda   or   Toyota

INPUT CLUTCH SPLINE:     10-(1-3/8)   18   26	INPUT PILOTS:   Ford     Chevy     Chrysler                             AMC     Other:
BEARING RETAINER:   Cast (Standard)                       Billet (Optional-#BRO)	FOR:   Ford     Chevy     Chrysler     AMC                  Other:
OPTIONAL CAGED ROLLER BEARINGS IN TAILHOUSING #KT-O: (Must use 1350YMW yoke with this option.)
SHIFTER:  Yes / No     [_]#499-8778-O (V-Gate Recommended)         #JH-500-O    (H-Pattern) LOCATION: 21-3/4" Standard     Other:                       (We offer 18" Minimum- 27-1/2" Maximum) *If you are ordering our manual shifter, you must specify shifter location
[_]Shift Arms:     #SA-DR     (**Do not check if already ordering shifter, above.)

[_]Roller Pilot Bearing #PB-A	[_]Yoke: #1350Y   or   #1350YMW	[_]U-Joint: #1872
[_]Shift Knob #163-0003	[_]T-handle With Roll-Button #153-8510	[_]Bellhousing
[_]Sealant #90003-B (LG)	[_]Rear Polyurethane Trans Mount
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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(For Jerico® Use Only)

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.