FAX

To:	Easier Vision	From:
Fax:	405 348-0758	Pages:	1
Phone:	405 216-0187	Date:
Re:	Easier Vision^® 1.2	CC:

Please provide us with the information below to allow us to process your order

Personal Information

Last Name: ________________________ First Name: __________________________ Middle Initial: ____________

Company Name: _______________________________________________________________________________________

Home or Business address: Business Home

Number/Street ___________________________ State/Province ________________ City _______________________

Zip/Postal Code ______________ Country ___________________________

Home or Business Telephone: Business Home

_________________________________

Email Address: Business Home

______________________________

Credit Card Information

Credit Card Type:

Visa MasterCard Discover American Express

Name on Card: (if different from above) _________________________________________________

Credit Card Number: (16 digits) ____________________

Expiration Date: Month _____ Year _____

Comments:

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