Order Confirmation Form
Please, fill out this form, sign and fax to Vision Glasses
at (917)677-4763. Also fax a copy of both sides
of your credit card and the driver license (or other valid picture id with
your billing address in it).
Customer's First Name:
_________________Customer's Last Name:________________________
Order Information:
Product Brand: _________________Model:
__________________Color:_____________________
Lens Type:
___________________________
Prescription Information (if applies):
OD Sphere: ___________Cylinder:
_______________Axis: _____________ADD: ____________
OS Sphere: ___________Cylinder:
_______________Axis: _____________ADD: ____________
Billing Address:
Street: ___________________________________________________City___________________
State: ________________ Zip Code: __________________
Country: ________________________
Phone: _________________________ E-mail:
__________________________________________
Shipping Address (if different from Billing):
Street: ___________________________________________________City___________________
State: ________________ Zip Code: __________________
Country: ________________________
Phone: _________________________ E-mail:
__________________________________________
Credit Card Information:
Card Issuer (Visa, MC, AMEX, Discover)__________ Card
Number: ___________________________
Expiration Date:_______/_______ Card Code (3 digit number
on the back) _________________
