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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
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 _______________________________________________________
VC02-MAN-Rev6.indd 9
Job#: 0.0637
Date: 01/29/13
Component Order Form
Price
Order Code
$9.95
CFS13GU24VLX 13 Watt Natural Spectrum
$6.95
Shipping & Handling
Subtotal
CT & VT Residents ONLY add 6% Sales Tax
Total Payment Enclosed
Title: VC02 Manual Update
Version: Rev6
Product
9
Bulb
®
1/30/13 12:40 PM
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