Mileage Programming Order Form

Customer Type

Are you a dealership or a private party? *DealershipPrivate Party

Vehicle & Cluster Information

Year *

Make *

Model *

Mileage to be Programmed *The mileage the new cluster should be set to

Part NumberPart number on the new instrument cluster

VIN *

RO # *Repair order number

Shipping & Contact Information

Shipping Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Name *

Phone *

Email Address *

Name of Dealership *

Billing AddressSame as my shipping address

Billing Street Address *Only needed if your billing address is different from shipping

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Customer Name and/or # *The end customer this cluster is for

Preferred Method of Return Shipping *

PO # *Purchase order number

Odometer Statement (Private Party)

Odometer Statement

Private party orders require a signed odometer statement. Fill in the fields below, then print the agreement that comes with your ticket, sign it, and put it in the box with your cluster along with a copy of your driver's license.

Driver's License # *Required on the odometer statement. Must match the license copy you include in the box.

Method of Payment *CheckCashCredit Card

Photo of Driver's License *Required. A clear photo or scan of the license of the person signing the odometer statement.

No file chosen

Odometer Statement Acknowledgement *I will print the odometer statement, sign it, and put it in the box with a copy of my driver's license.

Payment Method *

Confirmation EmailEmail me a copy of my responses

Please do not fill in this field.