Customer Order Form.  

Customer name: _____________________________________

Mailing Address: _____________________________________

City_______________________, State________________ Zip Code: __________

Phone # Home: ___(         )_______________________________

Work Number: ___(          )_______________________________

E-Mail Address: __________________________________

Make of Clock(s): _________________________________

Services Requested: ____________________________________

Number of items packed: ________________________________

Items enclosed: (key, hands, pend. bob, pendulum, etc.) ________________________

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Notes: _______________________________________________________________

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