Job#:
Title: VB05 Manual
Date: 9/24/10
Version: VB05-MAN-Rev6
5
Component Order Form
Cut Along Dashed Line
Order Online at www.verilux.com/parts-and-accessories.
Mail or Fax your order by using this form to:
Verilux, Inc., 340 Mad River Park, Waitsfi eld, VT 05673
Fax:
802-496-3105
Quantity
Price
Part Number
Product
$12.95
VEX-035
USB Adapter
$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 ________________________________________________________
Authorized Signature
(credit card purchasers ONLY)
______________________________________________________________________
Ship to Address ______________________________________________________
______________________________________________________________________
______________________________________________________________________
Phone Number _______________________________________________________
Email Address ________________________________________________________
VB05-MAN-Rev6.indd 5
VB05-MAN-Rev6.indd 5
9/24/10 10:51 AM
9/24/10 10:51 AM
