Verilux ReadyLight VB05 Quick Manual - Component Order Form
5
Component Order Form
Cut Along Dashed Line
Order Online at www.verilux.com/parts-and-accessories.
Mail or Fax your order by using this form to:
Verilux, Inc., 340 Mad River Park, Waitsfield, VT 05673
Fax: 802-496-3105
Quantity
Price
Part Number Product
$12.95
VEX-035
USB Adapter
$6.95
Shipping & Handling
Subtotal
CT & VT Residents ONLY add 6% Sales Tax
Total Payment Enclosed
Payment Method:
❏
VISA ❏MASTERCARD ❏DISCOVER ❏AMERICAN EXPRESS ❏CHECK
Name as it Appears on Card
______________________________________________________________________
Credit Card Number __________________________________________________
Expiration Date _______________________________________________________
Security Code ________________________________________________________
Authorized Signature (credit card purchasers ONLY)
______________________________________________________________________
Ship to Address ______________________________________________________
______________________________________________________________________
______________________________________________________________________
Phone Number _______________________________________________________
Email Address ________________________________________________________