Jewelry, Diamond, Diamonds, Engagement Rings Philadelphia

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It's as easy as 1-2-3

	Give us a little bit of your contact information
	Joining our mailing list will give you a cusomer appreciation coupon to use on your next purchase!

I am filling out this form because

I want to join the mailing list
(either a Address or an Email is required)

I want to become part of the Customer Referral Program
so that I can receive my $10 Gift Cheque when I refer someone and they make a purchase
(Address is required)

	Give us a little bit of your contact information
	Please complete the form below so that we have some information to get a hold of you. We also need this information to send you your gift cheque if you are part of our Customer Referral Program

	Salutation	First*	MI	Last*
Your Name*

Address	Street Address
	Street Address 2
	City		State	Zip Code *

	(either your Email OR your Telephone are required)		example
Contact Info*	Email		e.g. yourname@organization.com
	Telephone		e.g. 999-999-9999

	Tell us a little bit about yourself
	Please provide us some information about yourself so that we can personalize your shopping experience

Dates to remember

	Month	Day
Birthday
Wedding Anniversary
(fill in your special dates if you wish or simply leave blank ...this is optional)

Gender

Male

Female

I am interested in

Engagement Rings

Semi-Mounts

Wedding Sets

Wedding Bands

Bracelets

Earrings

Necklaces & Chains

Pendants

Rings

Watches

Three Stone Rings

Cluster Rings

(select as many as you wish or simply leave blank ...this is optional)

How did you hear about us?

Bill Board (Bill Board on Highway)

Internet (Referring websites, Search Engines, etc)

Print (News Paper & Magazine Ads)

TV (Television Commercials)

Radio (Radio Commercials)

Word of Mouth (Family, Friends, co-workers, etc)

Other (or Not Listed)

(select as many as you wish or simply leave blank ...this is optional)

Questions or Comments

Occasionally Unclaimed Diamonds sends out promotions and valuable coupons (both as hard copies in the mail and as electronic emails). If you want hard copy coupons in the mail, please make sure that you have filled in the address fields above.

We take your privacy seriously at Unclaimed Diamonds. We want your shopping experience at Unclaimed Diamonds as well as you browsing experience at our website to be a positive one. We are collecting some information to help serve you the customer better. We can assure you that any personal information collected will be treated as confidential and that your personal information will not be sold or given away to any third party.

Note: The four fields in red with the asterisk (*) are required (First Name, Last Name, Email, Zip Code)

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