Roberts Eyewear
BifocalSafetyglasses.com
5480 San Juan Ave
Citrus Heights, CA 95610
Tel: 916-967-1980
Fax: 916-966-1223
Email: robertseyewear@gmail.com

Purchase Order No: __________________
Date:__________________

Billing Information

Name

Street

City                                    
                                                         State            Zip

Phone

E-Mail

Shipping same as Billing >>>___________<<< Please Check

Shipping Information

Company Name

Attn:

Street

City                                  
                                                          State           Zip

Phone

E-Mail

 
QTY. ITEM NO. NAME OF ITEM ITEM PRICE TOTAL
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SHIPPING CHARGE

   Domestic $99.00 & over

 $0.00

    $89.99 & under

 $6.95

    2-3 Business Days

 $15.00

    Canada

 $20.00

    International

 $30.00

TOTAL: $__________

TAX 8.75% CA RESIDENTS ONLY
TAX AMOUNT: $ __________

GROUND SHIPPING: $ __________

EXPRESS SHIPPING:$__________

 TOTAL ENCLOSED: $ __________
 
 
METHOD OF PAYMENT:   
 Money Order   
 *Personal Check

* (5 days hold on personal checks) Payable to: Roberts Eyewear

Charge to:   
 Visa   
 MasterCard   
 American Express   
 Discover

 

Card #                                                                               Exp. Date        /       

 

Cardholder's signature                                                                                       

 

By signing below, I certify that I have read and understand the policy.
 

X ________________________________________

Orders will not be accepted without signature

Thank you for your order!

Visit  safetyglasses.com  for Guarantee & Return Policy