Fill out this form as completely as possible. Items marked with an asterisk (*) are required information. Send the form by checking the authorize box and clicking the submit button at the bottom of the page. Please allow 1 to 2 business days to process your request.
Date of Birth*
Own or Rent?*
Monthly Payment or Rent*
Owned or Rented?
Monthly Payment or Rent
Name of a relative not residing with you*
Length of Employment*
Length of Employment
Date of Birth
Own or Rent?
Name of a relative not residing with you
Item numbers of the jewelry you would like to purchase*
Comments or additional information you would like us to consider.
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I authorize The Alexis Collection, LLC to verify the accuracy of the information provided on this form. *