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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 $2,500.00 US dollar deposit is required in cash, cashier's check or money order

5-SPEED DRAG RACING TRANSMISSIONS:   Circle, check, and fill in the choices below
MAKE: Chevy   Ford   Mopar   AMC   Other:		MOTOR: Big Blk.                        Small Blk.	CU. IN:
BODY STYLE:	WEIGHT:	CLASS:
TRANS:     Clutch-Type: #5S-DR     Clutchless: #5S-CL     Clutchless Shorty: #5S-SCL

INPUT CLUTCH SPLINE:     10 - 1.375 Ford Pilot - 8-1/8" or 8-5/8" Can     18 - 1.170 Ford or Chevy Pilot - 7-1/2" Can     26 - 1.125 Chevy Pilot - Standard Can	INPUT PILOTS:   Ford     Chevy
	BEARING RETAINER FOR:   Ford     Chevy
SHIFTER:  Yes / No     [_]Air #5S-AS   [_]Manual #5S-MS-O   LOCATION*:     *If you are ordering our manual shifter, you must specify shifter location
[_]**Shift Arms:     #SA-DR5         (**Do not check if already ordering shifter, above.)
[_]Roller Pilot Bearing	[_]Yoke: #1350YMW	[_]U-Joint: #1872
[_]Trigger Handle #5S-ASTH	[_]T-Handle With Roll-Button #153-8510	[_]Sealant #90003-B
[_]Air Regulator #5SR250	[_]Small Parts Kit #SPK-A5SP	[_]Oil #TLQ
EXTRA GEAR SETS:	[_] 1st Gear Set #5S1S    /          [_] 2nd Gear Set #5S2S    /      [_] 3rd Gear Set #5S3S    /          [_] 4th Gear Set #5S4S    /
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.