To order your sunglasses via fax, please fill out this form completely except
for your credit card number. Please print the form by clicking your browser's print icon.
Enter your credit card number on the printed form, and sign and date
the form at the bottom. Once you have completed all of the above, please fax your
order to 1-801-746-0504.
First name M.I. Last name
Street address
Address(cont.)
City State Zip code
Home Phone Work Phone
E-mail
Please provide the following ordering information:
QTY Model(ex:W2188) DESCRIPTION PRICE EA. TOTAL PRICE
Total Order:
Shipping & Handling: $5.95
*For all shipments to New Jersey addresses, please add New Jersey Sales Tax: 6.00%:
Total Charges:
Note: if your total is different from the actual amount due, we will notify you via email before processing the order.
Please Provide the following payment information:
Payment type
Cardholder name:
*** Fill in once you print this form ***
Credit card Number:Expiration date:(ex.09/99)
Issuing Bank: (ex. First Card)
I have read your return and exchange policy and agree to pay for the above goods and services:
