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General Information
Contact Name:
  
Business Name:
  
Address:
  
City, State, Zip:
  
Phone:
  
Fax:
 
Email:
 
Aircraft Information
Aircrcaft Reg. Number:
  
Aircraft Make:
  
Aircraft Model:
  
Aircraft S/N:
  
Engine Make:
  
Engine Model:
   (If unsure type "unknown")
S/N:
T.S.O.H.
Spec. #:
Engine Accessories Requested (at time of overhaul)
  Magnetos Carburetor   Turbocharger
  Ignition Harness   Vacuum Pump
  Sparkplugs GAMIjectors   Relief Valve Other
  Starter Alternator   Controller Other
  Exhaust Systems (Homebuilt Only)   Inverted Oil Systems (Homebuilt Only)
Propeller or Governor Services Requested
  Propeller Overhaul or Reseal   DESIGNER*PROPTM    
  Governor Overhaul or Reseal   Gift Blades    
  Propeller Sales - New   Other    
  Governor Sales - New   Other    

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Ameritech Industries, Inc.  20208 Charlanne Drive  Redding, CA  96002  USA (530) 221-4470 Fax (530) 221-5201

FAA Repair Station #NO3R717L