IRLEN INSTITUTE 5380 E. VILLAGE RD.

, LONG BEACH, CA 90808 (562) 496-2550

TO SUBMIT AN ORDER: ORDER THROUGH OUR ONLINE STORE @ WWW.IRLEN.COM , EMAIL actng@irlen.com, FAX (562) 429-8699, OR MAIL
OVERLAYS THAT ARE TO BE EXCHANGED
MUST BE RETURNED WITHIN 30 DAYS.
OVERLAY ORDER FORM
UNITED STATES SHIPPING AND HANDLING CHARGES

PRICE LIST Cost of Order S/H Fee

1 - 10 $4.00 each 100 - 299 $3.00 each $ 0 - $ 24.99 $ 5.95
11 - 99 $3.50 each 300 + $2.50 each $ 25.00 - $ 55.99 $ 8.95
For orders of 150 of one color…...$1.85 each/$277.50 box
AQUA QTY $ 56.00 - $ 75.99 $ 10.95

BLUE-GRAY QTY
$ 76.00 - $ 99.99 $ 11.95
$ 100.00 - $199.99 $ 12.95
GOLDENROD QTY
$ 200.00 - $399.99 $ 39.95
GRAY QTY
$ 400.00 - $599.99 $ 49.95
GREEN QTY
$ 600.00 - $799.99 $ 76.95
PEACH QTY
$ 800.00 - $999.99 $ 86.95
PURPLE QTY
$ 1000+ $190.95
ROSE QTY

TURQUOISE QTY
METHOD OF PAYMENT
YELLOW QTY
□ PAYMENT ENCLOSED □ PURCHASE ORDER ATTACHED
SAMPLE PACK W/ READING BY THE COLORS ($49.50) QTY
□ VISA P.O. # __________________________
SAMPLE PACK W/O READING BY THE COLORS ($38.50) QTY
□ MASTERCARD PHONE: ( )_________-______________
# Of Overlays . . . . . . . . . _______ @ $ ______ =
□ AMERICAN EXPRESS
SALES TAX FOR CA RESIDENTS ONLY, ADD 9%
□ DISCOVER CARD
SHIPPING AND HANDLING FEES (See Chart)
CARD # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
TOTAL $
EXP. DATE ___/___ Security Code _________
SHIP TO: ___________________________________ __________________________
_________________________________________________________
AUTHORIZED SIGNATURE
_________________________________________________________________________________
10/13
_________________________________________________________________