Quality Watch Repair     3641 S.E. Morrison Street      Portland, OR 97214         1-503-239-1859

I work out of my house,  with my family in residence. If you are delivering your watch to me in person, my delivery hours are 11 to 4 Monday to Friday,  by appointment only. Please phone before you come  by.

Please complete the following form and enclose it with the watch you wish to have repaired. If you are sending more than one watch, please complete one form per watch.

I Will ship your watch back to you by  Registered Insured US Mail with a signature required. Please use the address you want the watch shipped to.    

A note on shipping your watch to me.  I have had trouble with DHL and Fed-EX ground leaving packages on my porch without knocking.

NAME: ___________________________________Street: _______________________________________________________

City:_______________________________ State:___________  Zip:_________________ TELEPHONE: __________________________

Please Use Block Letters And Enter your E-Mail Address Twice For Accuracy  

E-MAIL: ___________________________________________________________________________________________   

E-MAIL: __________________________________________________________________________________________

WATCH MAKE AND MODEL:_____________________________________________________________________________

Have you noticed condensation in your watch ___Yes  ___No.    Does your watch get submerged in water?___ Yes  ___ No    If yes please explain so I can better estimate the repair needed.

 ___________________________________________________________________________________________________________________

So I am better able to time your (wind up watch). Which wrist do you wear your (wind up watch) on?_____________ 

DESCRIPTION OF REPAIR OR SERVICE REQUIRED: ___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

We accept Checks, Visa, MasterCard, American Express, and Discover Card      

I have enclosed credit card details___ or   I have enclosed a check for 20.00 to cover diagnostics and return shipping for up to three watches by registered insured mail.____  

Billing Address if different from shipping address:

NAME: ___________________________________Street: _______________________________________________________

City:_______________________________ State:___________  Zip:_________________ TELEPHONE: __________________________

Please Use Block Letters And Enter your Credit Card Number Twice For Accuracy 

CREDIT CARD NUMBER: ________________________________________________    EXPIRATION DATE:____________   CID Code______

CREDIT CARD NUMBER: ________________________________________________    EXPIRATION DATE:____________   CID Code______

(Credit card details above the $20.00 diagnostic and shipping fee will only be used upon completion of repair, and only after obtaining your authorization).

YOUR SIGNATURE: ____________________________________________________