Name: ___________________________________________________________

Address: _________________________________________________________

City: _______________________ State: ______________ Zip: ______________

Daytime Phone: ____________________ Evening Phone: __________________

eMail: ___________________________________________________________

Special Instructions: _________________________________________________

Method Of Payment

Check Payable To: _________________________________________________________

I, the undersigned, hereby state that I am over the age of eighteen (18) yrs old, understand the terms and conditions of the service and a legal resident of the United States. I state to having full ownership of enclosed property and having full authority to resell said property.

Signature: ______________________________________________________

Date: ___________________________________________________________

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Shipping Instructions
1. Pack your gold or diamonds securely in a manilla envelope or cardboard box. When packing, we suggest small ziplock bags or some sort of wrap (silver foil, etc) before inserting in the box or manilla envelope.
2. Fill out and sign this inventory record completely. Keep one copy for your records and enclose one copy in package.
3. Ship via United States Postal Service by using our complimentary USPS mailing label, which you may print off your computer. This method automatically insures packages for up to $500 through U-PIC insurance company. For value over $500, please mail and insure at your own expense. You may also ship via United Parcel Service (UPS) or FedEx at your own expense.

Mail your package to:
Olympia Ventures, Inc.
998C Old Country Rd Suite 327
Plainview, New York 11803.