The Wayback Machine - https://web.archive.org/all/20021013121057/http://aclens.com:80/printedorderform.asp

AC Lens Printed Order Form

Instructions
Print this form if you wish to order by Fax or Mail. Make sure your entries are complete and clearly legible so that your order is processed smoothly and your lenses arrive in a timely manner. Orders can be submitted by faxing to: 877-291-8154, or by mail to: AC Lens, 4691 Northwest Parkway, Hilliard, OH 43026

Name and Shipping Information  
Name:___________________________________ Are you a previous customer? (Y/N):_________
Street Address:____________________________  
Street Address 2:____________________________  
City:______________________ State:_________ Zip:__________________
Country:__________________________  
Tel(Day):__________________________ Tel(Evening):_________________________
Email:______________________________  

Your Prescription:
Eye (Circle):   Item Name/Description: Quantity: Price:
Right   Left   __________________________________ ____________ $____________
Right   Left   __________________________________ ____________ $____________
Right   Left   __________________________________ ____________ $____________
Right   Left   __________________________________ ____________ $____________
Shipping and Handling: $____________
Tax (Ohio residents add 5.75%) $____________
Total: $____________
 
Prescription Information (Please check one of the following):

My current prescription is on file with AC Lens

I am faxing/mailing my prescription together with this order (Fax to 877-291-8154)

Please obtain my current prescription from my Doctor.

Please provide the following information if you need this service:

Name of your Doctor or Optical Dispenser:_______________________

Doctor or Dispenser Phone No:________________________________



Payment Methods

Visa, MC, Discover, AM Ex, Check or Money Order (Payable to AC Lens)

Please check one of the following:

Payment by Check / Money Order (Make payable to AC Lens and mail to the above address)

Payment by Credit Card - My card information is already on file

Payment by Credit Card - My card information is as follows

Card Number:______________________________ Expiration Date:__________
Name appearing on card:_______________________________________________
Card Billing Address (only if different from above):
Street Address:_____________________________________________________
City, State Zip:_____________________________________________________
I accept the above charge:__________________________________(Signature)

Thank you for your order

Please double-check that your order is complete and legible, especially the shipping address and phone number.

Thanks again for choosing AC Lens.
http://www.aclens.com/