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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Quantity: ZIP Name
Phone Number
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Email for PayPal Invoice Notification:
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Alternate Email
Your Account Number (If Re-ordering)
Lens Quantity: RIGHT Lens(es):
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Lens Quantity: LEFT Lens(es):
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Shipping Method: With Tracking and Delivery Confirmation
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First Class Mail with Tracking
Priority Mail with Tracking
Express Mail (Overnight)
Payment Method (Select One)
PayPal
Money Order
Special Instructions/ Comments:
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