Clock Repair Request Form If you have a clock you’d like to have repaired, please fill out the clock repair request form below. Name (required) Email (required) Street Address City Zip Code (required, 5 digits) Phone (required) ----------------------------------------- What type of clock do you have? Grandfather/Floor ClockCuckoo ClockWall ClockMantel Clock400 day/Anniversary ClockAlarm ClockOther / Not sure ------------------------------------------ Do you know the brand of your clock? (i.e. Howard Miller, Seth Thomas, Ansonia, Junghans etc. Or, Not Sure/Can't tell) Please describe the issues or problems you are having with your clock: Would you like to be automatically put on our queue list for repair? YesNot At This Time Just to make sure you're not a robot... 4 x 4 = The Capital of Kansas Disclaimer: By sending this form, we are collecting data from you for the sole purpose of contacting you about clock repair.