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Customer Information          
                               
Name   E-Mail  
Address   City   State   Zip  
Phone                  Mobile     Day     Night  
                               
Watch Information        
Brand Name   Case Shape        
                               
                               
Visible Damage/Condition  
                               
                             
  Men's   Ladies   Child's   Pocket              
                               
  Yellow   White   2 Tone   Titanium                
                               
                               
Is your watch running?     Yes   No                
If it stops intermittently, is it at the same time every day?   Yes   No          
If your watch has a calendar, have you noticed any trouble with the day or date changing?   Yes   No  
Describe any other problems with your watch   
 
                               
LIMITATION OF LIABILITY:  By sending item(s) for repair, customer agrees that PTRC, Inc., its agents and representatives (“PTRC”) are accepting the item(s) solely for the purpose of repair.  PTRC shall not be responsible for loss, damage, or theft of the item(s) unless due to PTRC’s sole negligence.  Any damage or loss due to PTRC’s sole negligence will be limited to the actual cost to repair or replace the item(s) with item(s) of comparable value and is not to exceed the sum of $75.00 or such higher value as may be declared by customer in writing in advance.  In no event will PTRC be liable for other damages, including loss of use, or other incidental or consequential damages. Some states do not allow the limitation or exclusion of liability for incidental or consequential damages so the above limitation or exclusion may not apply to customer.  Ohio law shall govern.  All disputes shall be resolved in Lucas County, Ohio.  In no event shall PTRC be responsible for items unpaid more than 90 days past notification of completion.
Signature X   Declared Value $