Job#: Title: VB05 Manual
Date: 9/24/10 Version: VB05-MAN-Rev6
5
Component Order FormCut 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, Waitsfi eld, 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 ________________________________________________________
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