Fillable Service Order Form 281-738-3635) 9675 Southwest Fwy, Houston,

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Service Order Form 281-738-3635) 9675 Southwest Fwy, Houston,

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The Service Order Form 281-738-3635) 9675 Southwest Fwy, Houston, form is 1 page long and contains:

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  • 10 check-boxes
  • 20 other fields

Country of origin: OTHERS
File type: PDF

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Service Order Form
9675 Southwest Fwy, Houston, TX 77074
(
281-738-3635)
Place the injectors in plastic bags before
you pack them in the shipping box. To allow us to
match, please leave old O-rings and spacers on the injectors. Send this completed form with
the injectors to: Injector Rx, 9675 Southwest Fwy, Houston, TX 77074. For Help call us.
281-738-3635
Note: If you do not have a printer please include a hand written note with the fuel injectors that
contains at least your name and a contact phone number.
Name ………………………….…………………………………. Phone …..…….………
Address ….……………………………………………………………………………………..
City ..………………………………………….……... State ……… Zip …………….
Email …………………………………………………………..
Vehicle, Year & Make ……………………………….. Model …………………………….
Total Number of Injectors ……………
Check the appropriate box below for the desired service requested.
Note: 1 tube of o-ring grease covers about 4 injectors indicate quantity required in box below
Clean and Flow ($18 per injector)
Same day service ($25.00 per injector)
Install Hose Ends ($6.00 per injector)
O-ring Grease ($1.00 / Tube)
Flow Test Only ($10.00 per injector)
Other, Please specify on back
Shipping:
$9.00: Up to 8 injectors = Small Flat Rate Priority Mail
$15.00: More than 8 injectors = Medium Flat Rate Priority Mail
Insurance can be purchased for $1.65 per $100 of coverage. Please indicate insurance required $................................
Payment Method: Visa Master Discover Amex PayPal
1. Credit Card Details: (If you do not wish to supply this info, leave blank we will call for payment)
Name as it appears on card ………………………………………………………………………...
Billing Address …………………………………………………………………Zip …………….
(Only if different than shipping address)
Card Number …………………………………… Expiration Date ………………CSV……….…
Authorization to use Credit Card:
Signature ……………………………………………………………Date: ………………………
Or:
2. PayPal Email Address …………………………………………………………………………..
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Service Order Form 281-738-3635) 9675 Southwest Fwy, Houston,

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Completed 24 March 2021

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