Text Box: Replacement Lenses Order Form
Text Box: Vircol Optical

See Clearly with our Lens Service
Text Box:  
42 Commerce Drive
Farmingdale,  NY  11735 DATE
Phone 631-414-7002   
Fax     631-414-7003
info@vircoloptical.com
Name   Ship To If Different From Billing Address
Street Address   Name  
City   Street Address  
State / Zip Code   City  
Daytime Phone   State / Zip Code  
Cell Phone
E-Mail Address          
SHIPPING METHOD    
USPS - Priority Mail    
All Sunglass Lenses are CR-39 Plano unless otherwise specified.  Lenses are sold in matched pairs we will match the color lens as close as possible
to the original lens in your sunglasses we can not guarantee color will be exact, However they will be as close as possible
QTY   DESCRIPTION     UNIT PRICE LINE TOTAL
        
        
        
        
        
        
Shipping & Handing charges for 48 US Continental States  Shipping  $6.95
 
SUBTOTAL
Paypal Customers Include 8.625% NYS Sales Tax  
Transaction # TOTAL   
  
Please Make all Checks & Money Orders Payable to    
Vircol Optical
All New York State Residents add 8.625% Sales Tax
All Credit Card orders are payable through Pay Pal on Our Web Site
 Authorized by   Date