Verilux VB05 Component Order Form, Payment Method, Ship to Address Phone Number Email Address

Component Order Form

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

Cut Along Dashed Line

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 ________________________________________________________

VB05-MAN-Rev6.indd 5

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Job#:	Title: VB05 Manual
Date: 9/24/10	Version: VB05-MAN-Rev6

9/24/10 10:51 AM