Vehicle information:

 Make______________________  Model_______________________  Year______

 Mileage________________________ 

           Please check what the primary problem is

 __Dead or Dim    __Flickers    __Erratic    __Reads incorrectly          

          Please check which function is not working

 __Speedometer     __Tachometer     __Volt     __Oil     __Fuel 

 __Temp   __Odometer   __Backlight   __Other (explain below)

 VIN#_________________________________

ALSO INCLUDE A COPY OF THE PAYPAL TRANSACTION WITH

CLUSTER, if you paid by paypal……….

  NAME:    _________________________________________________________

 ADDRESS:________________________________________________________

CITY:      _____________________________________________

 State:        ___________________________

 Zip code: ____________________________

 Phone #: _____________________________

 Email:__________________________________________________

 THANKS FOR THE ORDER………………….

 David Ruberg
123 W. Sarnia St.
Winona, Mn 55987
507-429-4489