Cut Along Dashed Line
Component Order Form
Order Online at www.verilux.com/replacement bulb Mail or Fax your order by using this form to:
Verilux, Inc., 340 Mad River Park, Waitsfield, VT 05673 Fax:
Quantity | Price | Order Code | Product |
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| $19.95 | CFML27VLX | 27 Watt Natural Spectrum® Bulb |
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| $6.95 | Shipping & Handling | |
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| Subtotal |
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| CT & VT Residents ONLY add 6% Sales Tax | |
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| Total Payment Enclosed | |
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Payment Method:
❏VISA ❏MASTERCARD ❏DISCOVER ❏AMERICAN EXPRESS ❏CHECK
Name as it Appears on Card
_____________________________________________________________________
Credit Card Number_ _________________________________________________
Expiration Date_______________________________________________________
Security Code (from back of card)______________________________________
Authorized Signature (credit card purchasers ONLY)
_____________________________________________________________________
Ship to Address_ _____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Phone Number_______________________________________________________
Email Address________________________________________________________
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