Please print this page, fill it out and mail to us.

REGISTRATION FORM

*    required field

* Report Number: __________________                                          

* Last Name: ______________________

* Middle Initial: ____________________

* First Name: ______________________

* Address: _____________________________________________________________

* City: ________________________________________

* State: ___________       * Zip: ______________

* Email Address: ___________________________________

Certificate:

Registration only ($25.00)

 Register and Purchase Certificate ($45.00)

Update Registration Information

Update Replacement Value ($25.00)

Order a reprint ($5.00)
Payment Method:

 Visa            Card Number: ___________________              Expiration Date: _______________

 Master        Card Number: ___________________              Expireation Date: _______________

 American Express      Card Number: ____________________          Expire Date: _________________

 Check  (included)

            ___________________                             ________________
              Customer Signature                                           Date

Mail to:  Independent Gemological Laboratories
             21 West 38th Street    
             New York, NY 10018