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Order Confirmation Form

Please, fill out this form, sign and fax to Vision Glasses at (917)677-4763.  Also fax a copy of both sides
of your credit card and the driver license (or other valid picture id with your billing address in it).

Customer's First Name: _________________Customer's Last Name:________________________

Order Information:

Product Brand: _________________Model: __________________Color:_____________________

Lens Type: ___________________________

Prescription Information (if applies):

OD    Sphere: ___________Cylinder: _______________Axis: _____________ADD: ____________

OS     Sphere: ___________Cylinder: _______________Axis: _____________ADD: ____________

Billing Address:

Street:  ___________________________________________________City___________________

State: ________________ Zip Code: __________________ Country: ________________________

Phone: _________________________ E-mail: __________________________________________
 

Shipping Address (if different from Billing):

Street:  ___________________________________________________City___________________

State: ________________ Zip Code: __________________ Country: ________________________

Phone: _________________________ E-mail: __________________________________________
 

Credit Card Information:

Card Issuer (Visa, MC, AMEX, Discover)__________ Card Number: ___________________________

Expiration Date:_______/_______ Card Code (3 digit number on the back) _________________

I hereby confirm that the information provided is correct and authorize Vision Glasses to process the specified
order and charge my credit card accordingly.

DATE __________________ SIGNATURE __________________________________

 


Vision Glasses is a unique store offering only the most fashionable top designer eyewear and sunglasses: Kazuo Kawasaki glasses and Silhouette glasses. Our designer eyewear collections are constantly updated, offering you the best and latest models. Our eyeglass frames prices are among the lowest in the industry, yet all our glasses and sunglasses are authentic. We simply do not sell replica eye glasses. Our sales representatives are happy to assist you buying eyeglasses online. Whether you need to order eyeglass frames online or need to order prescription eyeglasses or prescription sunglasses online, our highly skilled lab technicians are here to assist.