Watch WARRANTY Repair Ticket Information (one form per watch, please):   
NAME:_____________________________________________ 
Address:___________________________________________ 
City:___________________________ 
State: ____________ ZIP:__________ 

DAY PHONE:______________________________ 

EVENING PHONE:___________________

CELL PHONE: ____________________

E-Mail:_________________________   

Watch Description (circle appropriate info):    
Gent’s                  Ladies’     

Mechanical             Quartz          Kinetic

Yellow          White            Two/Tone           Titanium   

Brand____________  Case back# or style # from back of watch:_________________
(Seiko's # is 8-digits and next to word Seiko on curved edge or center)
Stones (Y/N)         Color of Stones:

Water Resistance Level:                     

PLEASE INDICATE:  Insurance Value*$_________(Actual Replacement Value Only) *OUR MAXIMUM LIABILITY FOR THIS ITEM  IS $100 UNLESS A SPECIFIC VALUE IS STATED HERE.  Your return shipping charges are based on this amount.

Is the Watch Running?  ____ Yes      ____ No

Please describe problem: