Shipping Information:
Name ______________________________________________
Address ____________________________________________
Address ____________________________________________
City, State, Zip______________________________________
Telephone __________________________________________
FAX _______________________________________________
P.O. #______________________________________________
FAX order to: +1-765-482-5660
The Lebanon Corporation
1700 N. Lebanon St.
P.O. Box 588
Lebanon, Indiana 46052
USA
Telephone: 1-800-428-2310
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Credit Card Number (American Express, Discover, MasterCard, Visa)
_____________ ____________ _____________ ____________ Exp Date ___________ / _____________
M M Y Y Y Y
Security Code from card ___ ___ ___ ___ (Visa, MasterCard, Discover have 3 numbers to the right on
the reverse of card in the signature line. American Express is on the front right side above the account number and is 4 numbers)
Signature: __________________________________________
Item #
2050
2055
150
200
210
3000
3005
701
703
706
650
300
325
400
500
600
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HONAN INTRAOCULAR PRESSURE REDUCER
REUSABLE EQUIPMENT
With reusable Bellows, Headband & Case------------------------------
With reusable Bellows, Headband,& Case + Relief Valve -------------
Bellows - Reusable -------------------------------------------------------
Single Headband - Reusable---------------------------------------------
Divided Headband - Reusable (Standard)--------------------------------
DISPOSABLE EQUIPMENT
With 1 box (12) disposable Bellows & Headbands, Case -------------
With 1 box (12) disposable Bellows & Headbands, Case +Relief Valve
1 box (12) single use disposable Bellows & Headbands ---------------
3 boxes (36) single use disposable Bellows & Headbands,
a discount of 2% ---------------------------------------------------------
6 boxes (72) single use disposable Bellows & Headbands,
a discount of 4% ---------------------------------------------------------
Adapter -------------------------------------------------------------------
FOR BOTH REUSABLE & DISPOSABLE EQUIPMENT
Tubing - black latex ------------------------------------------------------
Silicone Tubing (latex free) ---------------------------------------------
Relief Valve ---------------------------------------------------------------
Pressure Gauge ----------------------------------------------------------
Case - black vinyl w/ zipper --------------------------------------------
Prices are in US dollars.
August 1, 2009
Sub Total __________
(Prepaid and Add) Shipping __________
Total US$__________
Price
$280.00
$350.00
$33.00
$35.00
$3500
$280.00
$350.00
$95.00
$279.30
$547.30
$1.25
$4.00
$10.00
$75.00
$225.00
$6.00
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Qty
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Ext
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