Verilux VD11 User Manual
9
Job#: 0.0637
Title: VD11 Manual
Date: 02/08/13
Version: Rev9
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:
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
$12.95
CFS18GU24VLX 18 Watt Natural Spectrum
®
Bulb
$6.95
Shipping & Handling
Subtotal
CT & VT Residents ONLY add 6% Sales Tax
Total Payment Enclosed
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 _______________________________________________________
_____________________________________________________________________
Credit Card Number _________________________________________________
Expiration Date ______________________________________________________
Security Code (from back of card) ______________________________________
Authorized Signature (credit card purchasers ONLY)
_____________________________________________________________________
Ship to Address _____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Phone Number ______________________________________________________
Email Address _______________________________________________________
VD11-MAN-Rev9.indd 9
2/8/13 10:03 AM