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Service Center Name Contact Person
Address Email
City Phone
State (Providence) Fax
Zip (Postal) Code Order For: Stock Price Quote
Ship To (Same as Above): Yes No
Warranty Unit Down
Ship To (Different Than Above): Name
Address City
State (Providence)
Zip (Postal) Code
Attention
To Utilimaster Parts Department
Date
65528 State Road 19, P.O. Box 585
Wakarusa, IN 46573-0585, U.S.A.
Preferred Shipper
Fax 574-862-7637
(Carrier and Service Priority)
Purchase Order # Credit Card #
Authorized Signature Exp. Date:
Vehicle Year
Utilimaster Body S/N or Chassis VIN
Vehicle Model
Order
Item No
Quantity
Part Number
Part Description
Comments (Optional)
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Utilimaster Customer Service 800-237-7806 (or 574-862-3219)
UtilimasterPartsOrderForm7.indd (Rev. C, 11/11)