Salon Name 

    First & Last Name        Email Address 

    Street Address 

    City  ,    State        Zip Code 

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Order Form

EYECONES Roll(s) -250 pair per roll  Retail $39.00 - Promotional Rate $20.00 1 2 3 4 5 6 7 8 9 10 20 50 100 250 500 1000

Credit Card Type  VISA MASTERCARD DISCOVER AMERICAN EXPRESS   Credit Card Number 

Expiration Date:    3 Digit Security Code    Billing Zip Code 

Shipping  Preference U.S. prices ($4.50 for first  Roll. $1 for Each additonal Roll . Stand Shipping Only) UPS GROUND $4.50 UPS 2 DAY $9.00 UPS NEXT DAY $20.00 UPS NEXT DAY (EARLY AM) $40.00

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