To: Dale Manufacturing attn: David "Dale" Langsather 3425 Fairhaven Avenue N.E. Salem, OR 97301 (503) 364-8685
				revised 7/2010
	Sample Order Form: (Copy into an e-mail or enclose with harmonic balancer order) Return Address: __________________________________________ __________________________________________ __________________________________________ My contact telephone number: (_____) _____ - ___________ (when:__________) Car Make:____________________ Engine size:_________________ Year:______________ Special notes:_________________________ Has the timing mark slipped from its original position? _______Yes; _______No; ____Not sure. Insured value (if you decide you want insurance coverage: add $ 2.25 forr $100 value; $ 2.75 for $200; $4.70 for $300; $5.70 for $400;$6.70 for $500 coverage.):_______________________ List return shipper you request and type of service (ground, 3-day, 2-day, next-day): __________________________________________________________ (Usually I return harmonic balancers through the post office using their medium sized flat rate box, which usually costs $10.70 and is a 2-day air service.)(8 1/2 X 11 X 5 1/2") (Please review shipping tips box above). Harmonic balancer rebuild usually takes two business days. I return your harmonic balancer repainted (in two coats), gloss black being the normal color. Special painting instructions, or color requested (if available):__________________________________________________ Payment options: [ ] I will pay by my personal check, check # _______________. $_____________ [ ] I will be paying by credit card (visa, M/C, Discover, or American Express): card #: _______________________________ expiration date(mm/yy):___________security code:________ [ ] I would prefer you call me for my credit card number when my harmonic balancer is completed and is ready to be shipped back to me. [ ] I have enclosed a money order or check to cover this order.