ProSpex USA Order Form
Please Note: Presently, we are unable to take secured orders via the internet.
You may submit here at your own risk (although very safe, there is no security certificate attached to this form).
Or you may fill in this form, print and fax it to: (760) 743-2204, email us at: info@prospexusa.com,
or call us at (800) 973-5076. Sorry for any inconvenience. Please click here for warranty info.
Date: ,
First/Middle/Last Name:
Address:
City:   State:   Zip: 
Phone:   Fax: 
Best time to reach me is between: ••and••••at••
Email address:
To better serve you in the future, please answer a few questions:
Gender of user:
Age of user:
Which activities do you forsee
using your ProSpex glasses at?
(select all that apply):
 Baseball   Basketball    Boating    Climbing  
 Cruising   Cycling    Driving    Fishing  
 Flying    Football    Golfing    Hiking  
 Hunting    Jogging    Running   Sailing 
 Shooting   Skiing   Soccer   Tennis 
 Volleyball   Work   Other:  
Comments:
Occasionally we make our data available to other manufacturers of fantastic products. If you would like us to keep your information confidential, select this box.
Pricing:
Product Price per unit Quantity Total
ProSpex USA Original $29.95
ProSpex USA Slimline $26.95
Polarized ProSpex USA $34.95
Amber ProSpex USA $29.95
Yellow ProSpex USA $29.95
Clear ProSpex USA $29.95
Additional Lenses - Polarized $21.95
Additional Lenses:
Original, Amber, Yellow, Clear, Slim Line
 $19.95
Please specify which additional lens color(s) you need:  
Shipping & Handling ($4.95 a pair)
Sales Tax (7.75% CA only)
Total Amount:
We generally ship UPS 2-day ground. If you need shipment sooner, please call to make special arrangements.
Payment Method:
Name on card:
Card number:   Expiration Date: