Opticus Frames, Lenses, Goggles, Shields, Accessories Ordering Form

Opticus Frames, Lenses, Goggles, Shields, Accessories Ordering Form

Opticus, Inc. 760 E. Heartstrong Superior, CO 80027 phone 800-870-5557 local 303-499-0111 fax 303-499-0119

-Help us with our efforts in making quality custom products for you by ordering far in advance of your departure!
-To order your glacier glasses simply print out the page and fill it out, then fax to 303-499-0119 or call (800) 870-5557
-No orders will be processed until information and price are confirmed by phone in order to assure that the product you need is the product you get.!

1. Frames/Goggles - Please fill in the frame/goggle information. It can be one that we provide or you can supply your own

Manufacturer: (Bucci, Julbo, Adidas, etc)
Model:
Color (if applicable):
Size (if applicable):

o (Providing your own, or other) Make & Model ___________________________________________

2. Lenses - Read the lens description page, if you have any questions on which lens is right for you, just call!

Glacier Lenses:
o-Blue Tundra	o-McKinley	o-Silver Frog	o-Sierra	o-Malachite
Active Sport Lenses:
o-Gray Polar-80	o-Brown Polar-80	o-Cuprex	o-Citrex	o-Chrome Reflex
o-Azure Reflex	o-Froggy-the-Gremlin	o-Gold Rush	o-Blue Fusion

3. Lens Material :

o-Glass (heavier but more scratch resistant, $50 surcharge)

o-Plastic (lighter, more impact resistant)

4. Prescription and P.D. -Fill in your Rx and your P.D. measurement. (Distance between eyes, we must have a PD measurement to make RX lenses)
-Incorrect prescriptions supplied by you or your docutor will be remade at a 50% discount.

	SPHERE	CYL	AXIS	Bi-focal ADD (if applicable)	P.D. Measurement
O.D. (Right eye)
O.S. (Left Eye)

5. Accessories
o-Basic Sport Hard Shell	o-Zip case	o-Opticus Duramax Sport Case	o-Opticus Duramax Wrap Case	o-Beko Nose Guard
o-Soft Lok Leash	o-Clarity Fog Eliminator

6. Payment -Visa, Mastercard, American Express, Discover, cashiers checks and money orders are accepted.
-Finalized prices, or quotes will be given over the phone

Credit Card # _______________________________ Exp.date______

7. Receiving your goods

Your Name:___________________________	Phone Number: DAY (____)____________
Billing Address:__________________________	City__________________ State ____ Zip _______
Notes: