1. Type of clock (circle one) : Alarm Wall Other
2. Is the movement’s size over 12mm in thickness and 50mm in width, length, or diameter?
YES NO
3. Number of Jewels
4. Type of power (circle one) : Battery / AC Other
5. (If winding is needed):
length of time clock can operate before rewinding
6. Value Break : Movement
Case
Strap
Battery