Dear Employees, To obtain a pair of prescription safety glasses:

1. Dart will cover new prescription safety glasses every 2 years, and new lenses yearly. 2. Go to www.hi-techoptical.com/dart and print out the safety prescription order form or pick up your order form from Safety

and have it signed by your Safety Manager or Human Resources Representative. 3. Employee fills in their employee information on the Order Form. (Fill out top of form with name, ID#, phone, etc.) 4. You must have a current prescription that is less than two years old and must take the prescription with you to the

provider. a. If you do not have a current eye prescription, please call the provider below to set up an eye exam. b. Eye exams are the responsibility of the employee.

5. Take the Order Form and your prescription to the provider listed below. 6. Pick out frames and styles of lenses. 7. There are a series of options that are available for you to choose from. Some of these will cost you beyond what the

company will pay. 8. Dispenser will fill out the remainder of the order form and send it to Hi-Tech Optical, Inc. 9. Once Hi-Tech Optical, Inc. has manufactured your glasses, they will send them back to the provider, where you will pick

them up and get a professional fitting. Program Offers: No Cost to Employee Lenses: Frames: Permanent side shields, case, Polycarbonate F9800 and shipping included. Plastic CR39 A2500 Single Vision F6000 Bifocal D-28 Trifocal 7x28

*Must pay at time of order. Please make check payable to Hi-Tech Optical, Inc. or provide credit card number on order form.*

Lenses: Frames:

Progressives-Outlook $50.00 Group 2 $20.00 Progressives-Natural, Comfort $75.00 Group 3 $38.00 Standard AR Coating $35.00 Group 4 $40.00 Premium AR Coating $70.00 Groups 5, 6 $50.00 Standard Scratch Coat (CR-39) $5.00 Group 7 $69.00 Premium Scratch Coat $25.00 Roll Edges $6.00 Polish Edges $6.00

NO TINTS ALLOWED Providers : All Eye Care, P.A. Hours: 800 Dallas Hwy 77 #100 Mon, Wed, Thurs: 9am – 6pm Waxahachie, TX 75165 Tues: 1pm – 6pm 972-937-4433 Sat: 10am – 2pm Boyd Eyecare Hours: 700 Silken Crossing Ste 200 Mon, Fri: 9am – 5pm Midlothien, TX 76065 Tues: 9am – 7pm 972-723-2727 Wed: 10am – 5pm Sat: 9am – 12pm

Boyd Eyecare Hours: 1560 Hwy 287 N Ste 300 Mon, Tues, Wed, Thurs: 9am – 6pm Mansfield, TX 76063 Sat: 9am – 2pm 817-557-3937

Any questions please call Customer Service at Hi-Tech Optical, Inc.: 989-799-9390 or Fax: 989-799-3711

The employees are responsible for any upgrades. ALL CREDIT CARD CHARGES ARE MADE BY HTO. *Signature is required for Emp Credit Card charges.

Card Type: VI, MC, AX, DI

Credit Card Number (xxxx-xxxx-xxxx-xxxx)

Exipiration Date (MM/YY) CVV Total Amount

Signature:

*Required Fields

Bill To: 3149 Order Date

(MM/DD/YY)

Purchase Order #

*EmployeeLast Name

*EmployeeFirst Name

Employee #

*EmployeePhone

Frame Style Eye Bridge Color Temple

Sphere Cylinder Axis Prism Base

Right OD

Left OS

Add Power Seg. Height Distance PD Near PD

Right OD

Left OS

Prescription Eyewear Order Form Hi-Tech Optical, Inc.

3139 Christy Way South Saginaw MI 48603

(P) 800.638.1171 (F) 800.806.1663www.hi-techoptical.com

Frame Groups Co Pay Amount

1. F9800, A2500, F6000…………………………Included

2. SL-4, SL-5, SL-6, 7013, 7014, SW06……… 20.00

3. DP810, DP620………………………………………38.00

4. 7001, 7016……………………………………………40.00

5., 6. DG100, 7103……………………………….……50.00

7. EXT8………………………….…………………………..69.00

Lens Style Co Pay Amount

Single Vision......................................Included Bi-Focal……………………………………..…..Included Tri-Focal……………………………..…….……Included Progressive:

1. Outlook……………….……………..50.002. Natural……………….………………75.003. Comfort……………….…………….75.00

Bill-To: Account #: 3149

Dart Container 850 Solon Rd.

Waxahachie, TX 75165

Ship-To: Provider #: _____

Provider Name:Address:

Phone:

Lens Material Co Pay Amount

Polycarbonate ………….......................Included Plastic…………………………………….………Included Trivex………………………………..………………40.00

Tints & Coatings Co Pay Amount

Standard AR Coat…………….………………..35.00 Premium AR Coat……………………….…..…70.00 Standard Scratch Coat (Plastic Only)…..5.00 Premium Scratch Coat………….……………25.00

Other Options Co Pay Amount

Roll Edges…….……………..…………..……….6.00 Polish Edges……..…………….………………..6.00

Lenses Only Complete Pair Patient’s Own Frame Frame Only

Polycarbonate Plastic CR-39 Trivex

CLEAR POLYCARBONATE LENSES WILL BE SUPPLIED IF NOT SPECIFIED Clear Standard AR Coating

Other______________

Pres

crip

tion

Side Shields: Permanent

Doctor/Optician: Phone_______________________________ Fax ___________________________________ Signature ____________________________________________________________

Total $_____________

Signature_______________________

Single Vision Bi-Focal 28

Tri-Focal 28 Progressive ____________________________

Side Shields Co Pay Amount

Permanent ……….…………...................Included

Standard Scratch Coat (Plastic Only)Premium Scratch Coat

Premium AR

Dispensing Co Pay Amount

Dispensing Fee….…………....................Included

Plant Authorization

Print Name______________________________

F6000

Size 50 13•140 | 53 15•140 | 55 15•145

Color Gray FadeTemple Standard |

Cable 170mm Sideshield F6000 Brow-Guard

Size 50 53 55

A 49.7 52.3 57.1

B 44.3 45.0 50.0

ED 57.1 60.2 62.5

Group 1: Included Frames3M/Hoya

F9800

Size 46 20•145 | 48 20•145 Color SmokeTemple Standard | Cable 170mm Sideshield F98/99 Brow-Guard

Size 46 48

A 45.4 48.0

B 38.6 41.0

ED 49.3 51.7

Group 2: $20.00 Copay Frames

Hudson

A2500

NC

Size 55 19•130 | 58 20•130 Color Black/GrayTemple Standard Sideshield Integrated

Size 55 58

A 55.1 58.0

B 36.1 37.2

ED 57.9 60.9

Colors Sizes Temple Tips Side Shield Features

BROWN 50/18-145 tt-28a pss-85 Modern EyeshapeSLATE

53/18-150 in Clear Factory Assembled

or Smoke

SL-4

SLATE

Colors Sizes Temple Tips Side Shield Features

BROWN 50/16-145 tt-28a pss-50 Modern EyeshapeBURGUNDY

53/16-150 in Clear Factory Assembledor Smoke

SL-5

BURGUNDY

Colors Sizes Temple Tips Side Shield Features

BROWN 53/17-145 tt-28a pss-85 Modern Eyeshape

SLATE 56/17-150 in Clear Factory Assembledor Smoke

SL-6

BROWN

SIZE 52-17-140

54-17-140

56-17-145

52.00 34

54.00 35

56.00 36

7013PPermanent Side ShieldsMODEL 7013

• Front Material: Stainless steel• Temple Material: Stainless steel• Standards: ANSI Z87.1

CSA Z94.3

REMOVABLE SIDE SHIELD P/N 223

PERMANENT SIDE SHIELD ORDER 7013P

(7013P ONLY)

BLACK BROWN

bestseller

SIZE 51-18-135

53-18-13551.00 3

53.00 34

7014PPermanent Side Shields

MODEL 7014

• Front Material: Stainless steel• Temple Material: Stainless steel• Standards: ANSI Z87.1

REMOVABLE SIDE SHIELD P/N 224

PERMANENT SIDE SHIELD ORDER 7014P

BURGUNDYBROWN

Group 2: $20.00 Copay Frames

ArmouRx

70E

TITMUS SW06• Size: 57.16.125• Colors: BRN Brown/Orange Accents, BLK Black/Yellow Accents,

CLR Clear Body/Black/Yellow Accents• Features: Trogamid nylon, no metal content, removable/replaceable

dust dam, adjustable nose pads, 17° face-form wrap• No replacement temples, integral shield design• Standards: ANSI Z87.1-2010

Titmus

Group 3: $38.00 Copay Frames

3M/Hoya

DP810

Size 49 19•140 | 51 19•145 Color Brown | OliveTemple Spring Hinge Sideshield DP810 Brow-Guard

Size 49 51

A 49.1 51.1

B 32.6 34.4

ED 49.1 52.4

POLYCARBONATE LENSES ONLY

DP620 | stainless steel

Size 51 18•140 | 53 18•140 Color Black | BrownTemple Spring Hinge Sideshield DP620 Brow-Guard

Size 51 53

A 50.6 52.9

B 32.2 33.1

ED 53.0 54.7

Group 4: $40.00 Copay Frames

ArmouRx

MODEL 7001

DEMI AMBERBLACK

• Front Material: Cellulose acetate• Temple Material: Cellulose acetate• Standards: ANSI Z87.1

CSA Z94.3

REMOVABLE SIDE SHIELD P/N 211

PERMANENT SIDE SHIELD ORDER 7001P

(7001P ONLY)

SIZE

52-15-145

55-15-150

3 52.00

3 55.00

7001P

Permanent Side Shields

bestseller

52.00 28

7016PPermanent Side Shields

fr me fler

or

head

asmal

fit

MODEL 7016

BROWNBLACK

• Front Material: Cellulose acetate• Temple Material: Cellulose acetate• Small head fit• Standards: ANSI Z87.1

REMOVABLE SIDE SHIELD P/N 226

PERMANENT SIDE SHIELD ORDER 7016P

SIZE 52 -16 -135

Groups 5 & 6: $50.00 Copay Frames

Hudson

Colors Sizes Temple Tips Side Shield Features

BLACK 54/17-148 N/A pss-45

BROWN in Clear

SLATE or Smoke

Stylish Two-Tone Front(BLK, BRN) Plastic Dual Color Temples Spring HingesFactory Assembled

DG-100

BROWN

354.00

MODEL 7103

OLIVE PURPLE

• Front Material: Stainless steel• Temple Material: Stainless steel• Standards: ANSI Z87.1

CSA Z94.3

REMOVABLE SIDE SHIELD P/N 233

PERMANENT SIDE SHIELD ORDER 7103P

(7103P ONLY)

SIZE 54 -17 -135

7103PPermanent Side Shields

in 20new!

17

Group 7: $69.00 Copay Frames

Titmus

TITMUS EXT8• Sizes: 49.19.140; 51.19.145• Colors: BRN Brown, STL Steel• Features: Titanium, spring hinge, nickel-free plating• No replacement temples• Side shield: T-LOC® only, gray shield available, CS64/CS64S• Standards: ANSI Z87.1-2010

ArmouRx

Hi-Tech Optical, Inc. 12 Month Guarantee

Hi-Tech Optical, Inc. guarantees that products are free from defects in material and workmanship for 12 months from the date of purchase. If a product should fail during this period, Hi-Tech Optical, Inc. agrees to repair or replace the frame and lenses in the same style, color, size or nearest likeness at our discretion at no charge. This does not cover abused, scratched or lost glasses.

Progressive Warranty

Non-adapt or Prescription changes must be returned within 60 days to be remade at no charge.

Lens Warranty

Standard Anti-Reflection Coating has no warranty.

Premium Anti-Reflection Coating has a 1 year warranty, one time replacement.

Premium Scratch Coating has a 1 year warranty, one time replacement.

Frame Warranty

All frames carry a 1 year warranty under normal wear and tear at our discretion.