To order your sunglasses via the mail, please fill out this form completely
except for your credit card number. Please print the form by clicking your browser's print
icon. If paying by credit card, 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 mail your order to: MirageNet, Inc., 455B
Lawton Ave. Cliffside Park, NJ 07010 USA
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%
Shipping/Handling Charges:1-2/$5.95, 3-4/$8.50, 5-6/$11.00 (Continental US- Ground Shipping)
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 Please make all checks and money orders payable to MirageNet, Inc.
Cardholder name:
*** Fill in if paying by credit card ***
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:
