RGP Lens Company
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Name
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First
Last
Ship To Street Address
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City
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State
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ZIP Code
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Phone Number
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Payment State City
Email for PayPal Invoice Notification:
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Alternate Email
Your Account Number (If Re-ordering)
Lens Quantity: RIGHT Lens(es):
*
Lens Quantity: LEFT Lens(es):
*
USPS Shipping Method with Tracking and Delivery Confirmation
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Ground Advantage ($10)
Priority Mail ($14)
Priority Mail Express ($37)
Payment Method (Select One)
PayPal
Money Order
Special Instructions/ Comments:
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