Jewelry Repair Work Order Form:
Please use this sheet when sending your jewelry
Item
#
Manufacturer name or unsigned
With each piece circle one of the following
Do you want just stones?
Do you want me to set stones?
List other work wanted
1
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
2
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
3
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
4
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
5
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
6
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
7
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
8
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
9
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
10
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
11
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
12
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
13
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
14
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
15
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
16
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
17
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
18
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
19
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
20
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
21
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
22
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
23
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
24
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
25
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
26
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
27
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
28
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
29
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
30
  
Brac/Ear/Neck/Pin/Other
yes/no
yes/no
  
 
Name Phone Number   (h)                         (w)
Address City, State, Zip
Credit Card Number Visa/ Mastercard/ Discover
Name on Card Expiration Date
Check Number
Write the amount that you want your package insured for on it's return: $__________   
(A minimum of $100 )
 
HAVE YOU INCLUDED EITHER YOUR CREDIT CARD NUMBER OR CHECK?
ORDERS WILL NOT BE PROCESSED WITHOUT THEM. THANK YOU.

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Matthew Ribarich
Box 6483, Chesapeake, VA 23323
Phone or Fax (757) 558-9997