Engine Order Form:

Date____________

Company Name___________________________________

Address_________________________________________

_________________________________________

Phone #______________________Fax #_______________

Contact person____________________________________

P.O.#___________________

Tractor Size ___________________ Tractor Series__________

Tractor Serial # ___________________ Engine Size_______

Engine Serial # (required on all 504) ___________________

Select one: #1engine____________________ #2engine__________________

Select one:

Complete engine ____________

Manual kill ______ Electric kill ________

Short block ________________

Short block with head ________

Select one:

Turbo ___________

Non-turbo________

Engine Color:

Black __________

Yellow _________

Olive Drab ______

Cummins Beige_______

25% restocking fee + all freight charges on any miss ordered or cancelled engine sale.

All engines will be shipped to you freight collect. We pay return freight on selected returned cores.

Call us to see if your core is

eligible for free return freight

Shipping: YRC _______________________

R & L _____________________

UPS Freight ________________

Other _____________________ (please specify)

______________________

Customer’s signature

Return to: Hagan Tractor Parts, Inc.

Broken Arrow, OK 74014

800-365-0602

918-251-6393 fax