2015 Harley-Davidson® Performance Eyewear by Wiley X
Phone: +45 96 93 03 43
Wiley X Europe LLC Søndergade 8-10 7570 Vemb, Denmark
FOR WILEY X USE ONLY
Fax: +45 96 93 00 40 www.wileyx.eu
****PLEASE CONSULT WILEY X FOR CYLINDERS ABOVE -4.00**** STEP 1
BUYER INFORMATION PATIENT NAME:
Dealer Name / Billing Address / Delivery Address:
ACCT#
Name:
DATE:
Phone #
Birthday:
Contact Name:
Reference:
Dealer E-mail Address:
STEP 2
CHECK BOX FOR YOUR FRAME THEN CIRCLE YOUR COLOR CHOICE
HD ECHO
GLOSS BLACK / MATTE BLACK
HD ZEN
GLOSS BLACK
HD REBEL
GLOSS BLACK / TORTOISE BROWN
HD GRAVITY
MATTE BLACK / CRYSTAL METALLIC / GLOSS BLACK
HD SLAY
MATTE BLACK
HD DRIVE
GLOSS BLACK / MATTE BLACK
HD CURVE
GLOSS BLACK / COTTON CANDY
HD ZAK
MATTE BLACK
HD CRUISE X
GUN METAL / GLOSS BLACK
HD ROUT
GLOSS BLACK
HD CENSOR
MATTE BLACK
HD RANGER
MATTE BLACK
HD JAKE
GLOSS BLACK
HD MOJO
GLOSS BLACK METALLIC COFFEE
HD AIRRAGE
MATTE BLACK / GLOSS BLACK / CRYSTAL BRONZE
HD TWISTED
MATTE BLACK
HD BRICK
MATTE BLACK / CRYSTAL METALLIC / METALLIC BLACK
HD ABBY
ESPRESSO BROWN / RED SUNGLOW / CANYON BROWN
HD SHADOW
STEEL STREAK / MATTE BLACK / GLOSS BLACK / DRAGON
HD CHELSEA
LIQUID PLUM
HD ZONE
TORTOISE BROWN / MATTE BLACK
HD LACEY
COTTON CANDY
HD GEM
DARK TORTOISE FADE / MATTE BLACK / BLACK STREAK
HD GRIT
MATTE BLACK
HD TANK
PEARL BLUE / MATTE BLACK / GLOSS BLACK
HD MOTION
CHARCOAL PEARL / MATTE WHITE
ADDITIONAL COATINGS CHOOSE RX TYPE, LENS COLOR & TYPE BELOW
STEP 3 RX TYPE
LENS COLOUR
LENS TYPE
CLEAR SINGLE VISION
GREY
POLARIZED GREY POLARIZED
SMOKE GREEN YELLOW BROWN
TRANSITION BROWN
TRANSITION GREY
TRANSITION SOLFX
POLARIZED GREEN
FIRE BROWN
THUNDER BROWN
POLARIZED YELLOW
POWER PURPLE
TRUE GREY
ORANGE
STEP 4
TRANSITION
POLARIZED BROWN
TRANSITION
YOUR PRESCRIPTION SPHERE (SPH)
POWER MIRROR COATINGS
POLARIZED
CYLINDER (CYL)
ORANGE MIRROR
RED MIRROR
GREEN MIRROR
SILVER MIRROR
BLUE MIRROR
GOLD MIRROR LENS COATINGS
HMC COATING (STANDARD)
TRANSITION XTRACTIVE GREY
GLACIER COATING
DRIVEWEAR PHOTOCROMIC POLARIZED (GREEN)
GLACIER PLUS COATING
AXIS
R (OD) L (OS)
FAX THE ORDER TO +45 96 93 00 40 OR SEND AN E-MAIL TO HD-INFO@WILEYX.EU FAST PRESCRIPTION SUPPLY (8-10 WORKING DAYS) ORDER WILL BE DELAYED IF INFORMATION IS MISSING OR INCORRECT IN STEPS 1-4
PUPIL DISTANCE (PD)
PUPIL HEIGHT (PH)