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Owner Identification Form

Date Shipped to us ______________________

Name ________________________________

Address ______________________________

City _______________ St. _____  Zip______

Daytime phone number  (____) ____ - ________

Evening phone number   (____) ____ - ________

E-mail Address _________________________

Description of problem as best as you can describe.  






Numbers on weights   _______   _______
OR
Length of weights      _______   _______

 If you have an 8 day clock with music, YOU MUST CALL before sending it.