Company Details
Company Name
Customer Account No.
Address 1
    
Address 2

VAT No.
Town/City
Postcode

Contact Details
First Name
Main Contact Tel. No.
Last Name
Alternative Contact Tel. No.
Email address
Fax No.

Scrap Details - Gold
9ct
gms
15ct
gms
21ct
gms
10ct
gms
18ct
gms
22ct
gms
14ct
gms
20ct
gms
Fine
gms
Total grams
£ (Enter the calculated value of your items)

Notes - information you would like to tell us

Scrap Details - Platinum, Silver & Other
Platinum Weight
Silver Weight
Other
Weight
gms
Other
Weight
gms
Other
Weight
gms

Payment Method

Bank details - Please Enter Below

Select payment method

 
Account Holder
Sort Code
Account Number (8 digits)
 
Bank Name
Branch
For payment by cheque please provide payee name

Print this form then send with your items to:

Lois Jewellery Ltd 41 Frederick Street, Birmingham, West Midlands, B1 3HN