Order Form

Please Print this form, fill it out and mail or fax to:
SSVS Off-line Order Form
Sports Safety Vision System
PO Box 1384, Lomita, CA 90717
Headquarters:16434 Ishida Ave. Gardena, CA 90248
Toll Free: (888) 538-8478 Fax: (310) 532-5888 E-mail: info@rad-eyeguards.com

Name:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Telephone:
Fax:
E-mail:

Item No.	Frame Color	Lens	Price	QTY	Amount


	World Wide Airmail Costs:

Order Amount	Shipping Cost
Up to $99.99	US $8.00
$100.00 to $199.99	US $15.00
$200.00 to 399.99	US $22.00
$400.00 and up	US $30.00

Sub Total:
Shipping & Handling:
TOTAL:


	Type of Credit card: Master Card Visa AMEX Discover Diners Club JCB (Please circle one)

Card Holder Name:		Account#:
Expiration Date:		Signature:

Card Holder Address:


	(If different from above)


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