To
place an order, just complete the following information and fax or mail to:
Acu Light
CenterTM
2922 West
Magnolia Blvd
Burbank CA,
91505
Monday -
Friday 10 am - 7 pm
Saturday&Sunday by appointment
818.955.8601
www.aculightcenter.com
FAX:
818.955.8601
(Click here for U.S. shipping rates)
Shipping Address:
Company Name _____________________________________________
Name _____________________________________________________
Physical Address ___________________________________________
City, State _________________________________________________
Zip/Postal Code, Country _____________________________________
Daytime Telephone Number (very important!) _____________________
FAX Number (if you have one) _________________________________
Email Address _____________________________________________
(very important; please print clearly!)
Account Number ___________________________________________
Order Information:
Order Unit Total
Number Quantity Title Price Price
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Subtotal _________________
CA/CT/IL/MA/MI/MO/NJ/TN add State Sales Tax ______________
Shipping ______________
TOTAL______________
Payment Information:
__American Express __Visa __MasterCard __Discover __Check enclosed
______________________________________________ __________
Credit Card Number (13-16 digits) Exp. Date Card I.D.
______________________________________________
Print Name
______________________________________________
Signature
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