Edelbrock Media / Project Request Form

If you're a member of the print or electronic news media working on a project car, we'd like you to consider using Edelbrock parts. This form is strictly for Media/Project requests such as a magazine article or a TV show and should not be used for other types of requests, i.e. decals, etc. Please fill out the form below, and we'll give your request immediate consideration.

Date Items Needed By:

Contact Information

Publication

Requested By:

Title

Writer's Name

Business Address

Address

City

State

Zip

Country

Shipping Address

Address

City

State

Zip

Country

Phone

Cell

Fax

Part(s) Requested

E-mail

1. Qty

2. Qty

3. Qty

4. Qty

5. Qty

6. Qty

7. Qty

8. Qty

9. Qty

10. Qty

1. Part #

2. Part #

3. Part #

4. Part #

5. Part #

6. Part #

7. Part #

8. Part #

9. Part #

10. Part #

1. Description

2. Description

3. Description

4. Description

5. Description

6. Description

7. Description

8. Description

9. Description

10. Description

Reason/Purpose

Magazine Publication Date Product Exposure Plan

Special Instructions

By submitting this form, I certify that this project vehicle is intended for use in an article in a publication of general circulation, that it is not for private or personal use, and that Edebrock will receive appropriate mention as a supplier for this project.

To help us with our accounting and record keeping, we would appreciate a copy of your article as soon as it written. Kindly send it to:

Edelbrock Group
Attn: Trent Goodwin
3406 Democrat Road
Memphis, TN 38118

Thank You