Order Form
Home
Name:
Credit Card Billing Address:
City
State Zip
Shipping Address:
City, State/Province, ZIP:
E-Mail Address:
Phone: (if I have any questions):
Size
Band Length
Band width:
Quantity
Card Holder
Card #
Exp. Date 01 02 03 04 05 06 07 08 09 10 11 12 / 10 11 12 13 14 15 16 17 18 19 20
*Shipping/
Handling
Credit Card users fill out order form -PRINT-Then sign for authorization
Signature______________________________________ (Please print then sign)
I authorize Eye-GraFx to charge my credit card for the amount above.
Fax #: 1-918-343-2718 or mail to Eye-Grafx - P.O. Box 2433 - Claremore, Ok 74018
Make checks payable to: Eye-Grafx *S&H $00-$30 = $6.00 $31 & up shipping is Free
XX-Small
2" W X 1 3/4" H to
2 1/4 " W X 2 " H
X-Small
2 1/4"W X 2" H to
2 1/2"W X 2 1/4" H
Small
2 1/2 “ W X 2 1/4” H
2 3/4 “ W X 2 1/2” H
Medium
2 3/4" W X 2 1/2" H
3 " W X 2 3/4" H
Large
3 " W X 2 3/4"H
3 1/4" W X 3" H
*Convex (eye can blink) ~ Semi-Convex (can be worn under glasses/eye can blink) ~ Flat (for uses under glasses/eye can't blink)
Made in U.S.A.
Visa
Master
Card