ORDER FORM

ORDERING INSTRUCTIONS:
STEP 1: Photocopy this form and mark your selections

ITEM INVENTORY # SIZE QUANTITY x COST EACH = TOTAL

Additional P.O.S. Catalogs U5P142 8.5” x 11” FREE

Patient Brochure (Pack of 25) U5P135 3.5” x 8.5” FREE
Use and Care Guide (Pack of 50) U5P140 4.5” x 1.25” FREE
Dispensing Mat U5P141 18” x 13” FREE
UV Light Demonstration Kit U2M144 10.5” x 5” x 14” $90.00 USD
Lens Demonstration Card U5P136 5.25” x 3.5” FREE
Egg Poster U4P165 22” x 28” FREE
Magnifying Glass Poster U4P166 22” x 28” FREE
Kids Poster (Boy) U4P167 22” x 28” FREE
Kids Poster (Girl) U4P168 22” x 28” FREE
Easel Back Counter Card Display U5P144 8.5” x 11” FREE
Waiting Room Patient Information Video* (VHS) U5P145 7.5 x 4.25 x 1 FREE
Waiting Room Patient Information Video* (DVD) U5P146 5x5 FREE
Waiting Room Patient Information Video* (CD) U5P147 5x5 FREE

Optional materials (please specify): ________________________________________________ TOTAL COST:

in US Dollars

STEP 2: Please print the following information

Name: ________________________________________________________ Type of business:
Lenses Manufacturer Corporate Retail Chain/Buying Group
Practice Name: _________________________________________________ Wholesale Lab Retail Location/Independent
Address: ______________________________________________________
Payment Method: Visa Mastercard
City: _____________________________ State/Province: ______________
Name on card: _______________________________ Exp date: __________
Zip/Postal Code: ____________________ Country: ___________________ Number: _________________________________________________________
Phone: ____________________________ Fax: ______________________ Signature: _______________________________________________________

STEP 3: Place your order by mail, fax, or internet

United States:
Fax to: 1-888-316-6010
Web site: www.transitions.com
Mail to: Transitions Lenses Point-of-Sale
30 Terminal Way, Pittsburgh, PA 15219

For questions, please call US Customer

Service: Transitions is a registered trademark of Transitions Optical, Inc. © 2005 Transitions Optical, Inc.
1-800-848-1506, x7448

* Waiting Room Patient Information Video not shown in brochure.