Dealer - Fax Order Form
Please print then fax or mail:
Toll-Free: 800.EYES.4U2 (800.393.7482)
Phone: 707.829.2020
Fax: 707.829.2122

Allyn Scura Eyewear
708 Gravenstein Hwy. North #99
Sebastopol CA 95472
 Company Name:
 Buyer's Name:
 Order Date:
 Cust. PO#:
 Phone:(      )  Fax:(      )
 Email:
 Ship To:
 Street:  Unit#:
 City:  State: Zip:  Country:
 Bill To:
 Street:  Unit#:
 City:  State: Zip:  Country:
 
Allyn Scura - Vintage & Antique Eyewear
In the Vintage/Antique category, please make a note of the: Style# and Price.
Style#

Quantity

Site Price

 Extended Price
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Allyn Scura - Collections
Available with clear 'Demo' lenses or with a choice of sunglass lenses. In this category, please make a note of the: Style#, Frame Color Code#, Sunglass Lens Color (if applicable) and Price.
Style# Frame Color# Sunglass Color

Quantity

Site Price

Extended Price
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Domestic Shipping & Handling:

 
 Sub Total                         

*Shipping rates will be added to the final invoice. Rates and service providers are subject to change. All shipments insured at purchase price unless noted. 

Dealer Discount: -20% Discount                         
 
PAYMENT TERMS: Cashiers Check, Money Order, Credit Card or Business Check (product ships after payment is cleared). We accept MC, Visa, American Express & Discover. Extended Terms available for qualified accounts.
 


TOTAL                         

Method of Payment: __________________________
 
Type of Credit Card: __________________________
Credit Card#: _________________________________ Expiration Date:__________

Signature: __________________________________