NAME: _____________________________________________

ADDRESS: __________________________________________
___________________________________________________
___________________________________________________

PHONE: ____________________________________________

E-MAIL:____________________________________________
Your Privacy is important to us!  We do not sell or trade
our customers information: Privacy Notice
 

SERVICE NEEDED: __________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Ring Description & Value: _____________________________
___________________________________________________
___________________________________________________
(ie: 6 Band 14K Gold Ring $500.  This will determine how
much we insure your shipment for when we return your 
ring to you.)

Please choose your preferred method of payment.  If you are including a check or money order please make it payable to UCTUK LLC.

Check/Money Order: __________________________________

or Credit Card #: ____________________________________

Expiration Date: _____________________________________
CVV2 Number : _____________________________________

CC Billing Address (if different from above):  
___________________________________________________
___________________________________________________
___________________________________________________

Signature: __________________________________________

ORDER TOTAL: _____________________________________
(ie: $35 for 4 band solution)
 

Please print this form out and include it with your ring.  When shipping rings to us we ask that you please package carefully bands are easily bent.  We do not recommend bubble wrappers.  We also recommend you insure your ring for its full value.  Thank you and we will contact you as soon as we receive your ring!

If you wish to pay with check or money order please make checks/money orders payable to UCTUK

PLEASE MAIL TO:

puzzleRING Repair
1281 East Magnolia, Unit #D
Fort Collins, CO 80524