Watch Doctor Repair Payment Form

Note: your credit card will not be charged until the day your order/repair is ready to ship.

Please provide the following contact information:

Name

Work/Day Phone

Home Phone optional

E-mail

Your URL, we like to visit too!

Please provide the following ordering information:

Invoice Payment Information

INVOICE NUMBER	Payment Amount
	US$
	US$

Credit Card Information

This transaction is being transmitted via a secure server.

VISA Discover MasterCard American Express

Card Number:( NO SPACES) Make sure you include the last 4 numbers (Sometimes hidden in a hologram). All credit cards have either 15 or 16 numbers (example: 1111222233334444)

Expiration date: (example: 01/03)

Cardholder's name:

	Credit Card BILLING ADDRESS
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country

Please check all of your information and then submit the form.

Note: your credit card will not be charged until the day your order is ready to ship.

Name
Work/Day Phone
Home Phone	optional
E-mail
Your URL, we like to visit too!