<p> Irlen Diagnostic Clinic of North Carolina 212 Epping Road, Clemmons, NC 27012 fax: (336) 766-1487/cel: (336) 403-2524 [email protected] 5/1/2016 Assorted Overlays $2.75/each</p><p>AQUA ______</p><p>BLUE-GRAY ______</p><p>GOLDENROD ______</p><p>GRAY ______</p><p>GREEN ______</p><p>PEACH ______</p><p>PURPLE ______</p><p>ROSE ______</p><p>TURQUOISE ______</p><p>YELLOW ______</p><p>Total overlays: ______X $2.75</p><p>$ ______</p><p>IRPS forms ( packages of 50) X $22.00 = + $______</p><p>SHIP TO:______Total: $ ______</p><p>______NC Orders only: Sales Tax (6.75%) $______Shipping: $______Estimated Shipping cost: *For orders of $200 or more add 5% to the shipping cost. Total: $ ______Cost of Order S/H Fee $ 0 - $ 24.99 $ 5.95 $ 25.00 - $ 55.99 $ 7.95 $ 56.00 - $ 75.99 $10.95 Date ordered: $ 76.00 - $ 99.99 $11.95 $ 100.00 - $299.99 $12.95 $ 300.00 - $599.99 $19.95 $ 600.00 - $999.99 $36.95 $`1,000.00+ $40.95 OVERLAYS THAT ARE TO BE EXCHANGED MUST BE RETURNED WITHIN 30 DAYS.</p>