For Titmus Distributors Only

Note: If you are a consumer and would like to purchase a Titmus frame,
please call Titmus Customer Care at 800-446-1802 and ask for a distributor near you.

Account #

PO #

Order Date

Bill To:

Ship To:

Shipping Method

Authorized By

Fax Number

Please key in each frame or product selection as follows:
      Qty - Style - Color - Size

(Example: 10 - EXTS1 - C081 - 4821-140)

Side
Shields

Rx Name

Use ONLY if sideshields needed

Fill in RX Name, if needed