FACTORY DIRECT - Prescription Cycling Shoe
CUSTOMER INFORMATION
Name
(First)
(Last)
Address1
Address2
City
State/Prov
Zip/PostalCode
Country
Antarctica
Argentina
Australia
Austria
Belgium
Brazil
Canada
Chile
China
Cook Islands
Costa Rica
Czech Republic
Denmark
Djibouti
Fiji Islands
Finland
France
Germany
Greece
Greenland
Hungary
Iceland
Ireland
Italy
Jamaica
Japan
Mexico
New Zealand
Norway
Peru
Philippines
Poland
Portugal
Puerto Rico
Reunion
Russia
Singapore
Slovakia
Slovenia
South Africa
Spain
Sweden
Switzerland
United Kingdom
United States
Virgin Islands (British)
Virgin Islands (US)
Yugoslavia
Phone
Fax
Email
Comments
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PRESCRIPTION SHOE
Price
$1,350
plus casting fees
(please call for second pair discount from same cast)
Model
ROAD
TRIATHLON
MTB/MOUNTAIN
TRACK
Size
Small
Medium
Large
(what is the size of your current cycling shoes?)
Colors
Body
Silver
Black
White
Red
Blue
Yellow
Green
Orange
Gold
Toe
Silver
Black
White
Red
Blue
Yellow
Green
Orange
Gold
Straps
Silver
Black
White
Red
Blue
Yellow
Green
Orange
Gold
Heel
Silver
Black
White
Red
Blue
Yellow
Green
Orange
Gold
Embroidery
LEFT HEEL
RIGHT HEEL
(16 character max)
Cleat Setup
3-Hole (Look)
4-Slot (Speedplay)
MTB
B-bop
Platform Adjustments
None
Canting
Raise Platform
Fore/Aft Moved
Notes
Footbed
Standard
Custom Performance
Custom Comfort
SHIPPING
Ship Method
UPS Ground $19
UPS 3-Day Select $29
UPS 2nd Day $39
UPS Next Day $59
UPS International $149
check here if shipping address is same as above
Ship Name
Ship Address1
Ship Address2
Ship City
State/Prov
Zip/PostalCode
Ship Country
Antarctica
Argentina
Australia
Austria
Belgium
Brazil
Canada
Chile
China
Cook Islands
Costa Rica
Czech Republic
Denmark
Djibouti
Fiji Islands
Finland
France
Germany
Greece
Greenland
Hungary
Iceland
Ireland
Italy
Jamaica
Japan
Mexico
New Zealand
Norway
Peru
Philippines
Poland
Portugal
Puerto Rico
Reunion
Russia
Singapore
Slovakia
Slovenia
South Africa
Spain
Sweden
Switzerland
United Kingdom
United States
Virgin Islands (British)
Virgin Islands (US)
Yugoslavia
PAYMENT
VISA
MASTERCARD
Credit Card
Exire Date (mm/yy)
3 Digit Security Code (on back)
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