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Component Order Form
Cut Along Dashed LineCut Along Dashed Line
Order Online at www.verilux.com/replacement bulb
Mail or Fax your order by using this form to: Verilux, Inc., 340 Mad River Park, Waitsfield, VT 05673
Fax: 802-496-3105
Quantity Price Order Code Product
$14.95 CFS26GU24VLX 26-Watt Natural Spectrum
®
Bulb
$6.95 Shipping & Handling
Subtotal
CT & VT Residents ONLY add 6% Sales Tax
Total Payment Enclosed
Payment Method:
❏VISA ❏MASTERCARD ❏DISCOVER ❏AMERICAN EXPRESS ❏CHECK
Name as it Appears on Card
_______________________________________________________________________________________
Credit Card Number ___________________________________________________________________
Expiration Date ________________________________________________________________________
Security Code (from back of card) ________________________________________________________
Authorized Signature (credit card purchasers ONLY)
_______________________________________________________________________________________
Ship to Address _______________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Phone Number ________________________________________________________________________
Email Address _________________________________________________________________________
Thank you for purchasing this HappyLight Energy Lamp. For your warranty to be valid, this
Warranty Registration MUST be completed and mailed in a timely manner. Or, you can register
your product online at www.verilux.com/warranty.
Name ________________________________________________________________________________
Address ______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Phone Number _______________________________________________________________________
Email Address: _______________________________________________________________________
Model # ______________________________________________________________________________
Date of Purchase (Month/Day/Year) ____________________________________________________
Warranty Registration
VERILUX INC
PO BOX 451006
OMAHA NE 68145-5006
Please cut out form and send to:
Or register online at www.verilux.com/warranty
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