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Job#: 0.0637 Title: VC02 Manual Update
Date: 01/29/13 Version: Rev6
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
$9.95 CFS13GU24VLX 13 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 (frombackofcard) ______________________________________
Authorized Signature (creditcardpurchasersONLY)
_____________________________________________________________________
Ship to Address _____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Phone Number ______________________________________________________
Email Address _______________________________________________________
VC02-MAN-Rev6.indd 9 1/30/13 12:40 PM