Credit Card Authorization Form

ECM Programming Worksheet
Customer/Payment Information:

Name: __________________________________ Phone number: ___________________________

Name on credit card: ______________________ Credit card #: ____________________________

Expiration date: ____________ Security code: ______________ If Visa, Mastercard or Discover, the security code will be the last 3-digits printed on the back
side of the card. If American Express, the code will be the
4-digits towards the top right corner of the card.

Billing address: ____________________________ Shipping address: _________________________

_____________________________ _________________________

_____________________________ _________________________

I certify that I am the authorized holder and signer of the credit card referenced above. I certify that all information is complete and accurate. I agree to pay total amount according to a card issuer agreement. I agree to perform the obligations set forth by the card member’s agreement with the issuer. By signing below, I acknowledge this and understand that the ECM programming cost and shipping cost charged by HDT is non-refundable (unless otherwise stated).

Tuning Purchase Amount Authorized by Card Holder___________________________________

Signature: ____________________________________ Date______________________________

Brand of truck:

International ___ Peterbuilt ___ Cummins ___ Detroit ___

Freightliner ___ Volvo ___ Caterpillar ___ Volvo ___

Kenworth ___ Mack ___ Mack ___ Paccar ___

Mercedes ___ Sprinter ___ Mercedes ___

Model _____________

Engine & ECM specifications:

Year_____________

Horsepower _________

ECM P/N ____________

Engine S/N __________

Automatic or Manual transmission (circle one)

Please describe what you would like for us to do with our programming (add power, delete sensors, raise limiters, improve mileage, etc…):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Do you currently have a check engine light or problems with your vehicle’s performance? If so, which trouble codes and explain performance problem:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Send this form along with your vehicle’s ECM to:
Heavy Diesel Tuner
246 Covenant Dr NE
Cleveland TN 37323