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Contact Information
Full Name:
Email:
Phone:
Fax:

Shipping Information
Business Name:
ATTN:
Phone:
Email:
Fax:
Purchase Order #:
Street Address:
Line 2:
City:
State:
Zip:
Location has forklift for delivery. I will need liftgate delivery for this order. Delivery location is a commercial business address with normal business hours. Delivery location is residential, agricultural, a Church, School or business at home.

Billing Information
Copy from shipping address
Full Name:
Street Address:
Line 2:
City:
State:
Zip:
Payment Type:
Credit Card #:
Exp Date:
Sec Code:

Vehicle / Equipment Information
Vehicle Year:
Vehicle Make:
Engine Make:
Engine Model:
Fuel Pump:
Has California Emmissions:	What's this?
Secondary Oil Filter:	Yes No
:
CPL & HP:
Upgrades
Base Price:
Authorized Amount To Bill

Additional Comments

How did you hear about us?
Please specify

Terms & Warranty
I have read and agree to the terms of the Blackwater Engines Limited Long Block Warranty. This includes following the written installation instructions supplied with the Long Block.
I have read and agree to the terms of the Blackwater Engines Limited Long Block Warranty and would like to upgrade to the extended warranty coverage for an additional $250.00 for the Gold Warranty, or $500 for the Platinum Warranty (if applicable). This includes following the written installation instructions supplied with the Long Block.

Agreement
You will be notified if there are any additional shipping charges that may apply and you will be contacted by Blackwater Engines BEFORE any charge is billed to your card. By submitting this form you authorize Blackwater Engines to access all information herein and/or bill your credit card in the amount of the engine plus any applicable shipping charges. Furthermore you authorize Blackwater Engines to bill your credit card in the amount of the core and container charges, applicable for your specific engine, if they are not returned within thirty(30) days from the time of verified delivery to the customer. Additional charges may apply to returned cores that are damaged. Also, there is a 5% cancellation fee for any order that is canceled before shipping. If the order is canceled after the engine has shipped, but BEFORE the engine is installed, the fee will be 20%.
I Agree

Agreement

You will be notified if there are any additional shipping charges that may apply and you will be contacted by Blackwater Engines BEFORE any charge is billed to your card. By submitting this form you authorize Blackwater Engines to access all information herein and/or bill your credit card in the amount of the engine plus any applicable shipping charges. Furthermore you authorize Blackwater Engines to bill your credit card in the amount of the core and container charges, applicable for your specific engine, if they are not returned within thirty(30) days from the time of verified delivery to the customer. Additional charges may apply to returned cores that are damaged.

Also, there is a 5% cancellation fee for any order that is canceled before shipping. If the order is canceled after the engine has shipped, but BEFORE the engine is installed, the fee will be 20%.

I Agree