1. style and fashion
2. accessories
3. sunglasses

3139 Christy Way South
Saginaw, MI. 48603 Phone 800-638-1171
FAX:800-806-1663 EMAIL:[email protected]
Bill To: 2832
Acument PL-495 CPL-N/A
Acument, Belvidere Operations Camcar LLC. Name
Rhonda Engelkes 815-544-0331
[email protected]
ID #
826 East Madison Street
Belvidere, IL 61008
Order Date
I-E-EOM
Patient Information
Ship To:
Richard Nast (847) 404-9797
[email protected]
Ship To: Plant
826 East Madison Street
Belvidere, IL 61008
Phone #
(
435
)
Dispenser: To complete the Prescription Safety Glasses order form, please circle one or more items in each section below.
Polycarbonate
High Impact - 2.0 mm
Section 6 - Frames (Circle Frame Style)
Frame Group A Titmus:
SW06
Self Pay
Section 1 - Lens Material (Circle one material)
1
Self Pay
Included
Preferred Material
3M:
Included
ZT200
Duty to Warn: Polycarbonate is the most impact resistant material & recommended for all safety glasses.
Poly
Section 2 - Lens Style (Circle one style)
Glass, Plastic or Poly
Glass, Plastic or Poly
Glass, Plastic or Poly
$
$
$
-
Progressive-Standard Min.Seg.Ht.18 Glass, Plastic or Poly
$
-
Single Vision
Bifocals
D28 Only
Trifocals 7X28 Only
Styles are available in only those materials listed above.
NOTES:
Employees can only choose from the options that are listed on this order
form.
Eye Size Bridge Size Frame Color
Section 7 - Frame Options (Circle option requested)
Included
Integrated Side Shields
Side Shields are required for all employees.
Eyeglasses Case
Dispensing Fee
Shipping Fee
5001, 5002, 5003 Included
2035 $
2060 Included
Progressive Lens (Non-Adapt) or Doctor Error Warranty: No Refunds. Hi-Tech Optical will
remake the glasses in Single Vision, Bi-Focal or Tri-Focal at no charge or upgrade a progressive
at employee cost (one time only) if notified within 60 days.
Sphere
RX Prescription Information
Cylinder
Axis
Prism
Seg. Height for ALL multifocals
Add
Seg Height
Base
Must have PD
Distance PD
Vertex Pantoscopic
Tilt
Distance
Right
OD
Left
OS
Special Instructions:
Lenses Only
[ ]
RX Provider Signature:
RX Date:
Readers [ ]
Frame Only
[ ]
RX Provider Phone:
RX Expiration:
Near PD
Purchase Authorized By
Signature
Date
Title
3.6 - Acument-Belvidere-On-Site
12/17/2014 8:14 AM
I-E-EOM
Wrap
Angle
December 16, 2014
PRESCRIPTION SAFETY EYEGLASS PROCEDURE
Dear Employees,
1. Pick up your safety prescription order form and have it signed by your supervisor or manager.
2. If you do not have a current eye prescription, please acquire an eye exam appointment before
meeting with the dispenser.
** Eye exams are responsibility of employee.
3. Take the Dispenser’s Instruction Letter, Order Form, and your prescription to the dispenser.
(Fill out top of form with name, ID#, phone, etc.)
4. Pick out frames. Dispenser will fill out the remainder of the order form and send it to Hi-Tech
Optical.
5. Once Hi-Tech has manufactured your glasses, they will return them to the plant, where you will
pick them up.
Provider Information:
Richard Nast (On-Site Dispenser)
Limited availability at the Belvidere Operations
Location (Contact Rhonda Engelkes for details.)
Program Includes:
• Polycarbonate Lens Material
• Single Vision
• Bifocals D-28
• Trifocals 7x28
• Progressive (Hi-Tech Choice)
• Any Prescription Power
• Any Prism
• Any Multifocal Prescription Add Power
• Select Frames
• Integrated Side Shields
• Eyeglass Case
• Shipping (First Class Mail)
(Please see order form for complete list of available options.)
Acument Global Technologies will provide the Basic Hi-Tech Package of
lenses and frames at no cost to the employee. An employee can only
choose from the options that are listed on the order form.
Any questions please call Customer Service at
Hi-Tech Optical: 1-800-638-1171 or
Fax: 1-800-806-1663.
PRESCRIPTION SAFETY EYEGLASS PROCEDURE
December 16, 2014
Dear Richard,
To be in compliance with State and Federal Laws, this employee is required to wear Safety
Glasses. All examination fees will be the responsibility of the employee.
We ask your cooperation in completely filling out the attached prescription form including
pupillary distance, multifocal style, height, color of lenses, and all frame information.
There was previously a shipment made to you of sample frames which are included in this
safety eyewear program designed by our supplier, Hi-Tech Optical Inc., specifically for Acument
Global Technologies. Please call Hi-Tech customer support if you have any questions.
Basic Program Items Included:
Lens Styles:
Single Vision
Bifocals D-28
Trifocals 7x28
Progressive (Hi-Tech Choice)
Lens Materials: Polycarbonate
Any Prescription, Any Prism
Case
Shipping
Frames:
Please see order form and sample frames for selection of styles allowed.
Package Price: Acument Global Technologies will provide the Basic Hi-Tech
Package of lenses and frames at no cost to the employee. An employee can
only choose from the options that are listed on the order form.
After you have finished your examination and filled out the prescription form completely, please
return the form by fax or email. The completed glasses will be returned to the plant.
Thank you.
For additional questions, please contact:
Hi-Tech Optical Inc., Customer Service
3139 Christy Way South, Saginaw, Michigan 48603
Phone: 800-638-1171 or 989-799-9390
Fax: 989-799-3711 email: [email protected]
www.hi-techoptical.com
Hi-Tech Optical, Inc. 2013