9
Component Order Form
Cut Along Dashed Line
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: 802-496-3105
Quantity Price Order Code Product
$19.95 CFML27VLX 27 Watt Natural Spectrum
®
Bulb
$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 (from back of card) ______________________________________
Authorized Signature (credit card purchasers ONLY)
_____________________________________________________________________
Ship to Address _____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Phone Number ______________________________________________________
Email Address _______________________________________________________
