Register by Mail

    Please fill out, print and mail to us.

* (required field)                                        REGISTRATION FORM

* Report / Summary Number:
If your certificate doesn't have a report or summary number please send us a copy of your
certificate (front & back).

* Last Name:           * Middle Initial: * First Name:
* Address:
* City:    * State:    * Zip:
* Phone Number:
* Email Address:


Certificate Registration only                                    ($25.00)
Certificate Registration & Appraisal for Insurance ($65.00)
Update Retail Replacement Value                           ($25.00)
Update Registration Information   ( Address Change )

Payment Method:

Visa Card Number:   Exp.Date:
Master Card Number:   Exp.Date:
American Express Card Number:   Exp.Date:
Check  (included)

___________________                             ________________
Customer Signature                                               Date

Mail to: Independent Gemological Laboratories
            25 West 45th Street, Suite 1406
            New York, NY 10036