Varilux and Crizal Promotion
Claim Form
PAIRS ONLY PLEASE!!
Account Name (required)
Account Number (required)
1. Invoice Number (required)
“Varilux Lens Design ?”
Crizal Included ?Yes No
2. Invoice Number (required) “Varilux Lens Design ?”
Crizal Included ?Yes No
3. Invoice Number (required)
“Varilux Lens Design ?”
Crizal Included ?Yes No
4. Invoice Number (required)
“Varilux Lens Design ?”
Crizal Included ?Yes No
5. Invoice Number (required)
“Varilux Lens Design ?”
Crizal Included ?Yes No
6. Invoice Number (required)
“Varilux Lens Design ?”
Crizal Included ?Yes No
7. Invoice Number (required)
“Varilux Lens Design ?”
Crizal Included ?Yes No
8. Invoice Number (required)
“Varilux Lens Design ?”
Crizal Included ?Yes No
9. Invoice Number (required)
“Varilux Lens Design ?”
Crizal Included ?Yes No
10. Invoice Number (required)
“Varilux Lens Design ?”
Crizal Included ?Yes No
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