Viriguard Order Form

Purity
Athletic

Viriguard

Team Order Form

Prices

Purity Athletic will sell Viriguard units only to physicians or physical trainers at accredited public or private educational or correctional institutions. The price is $300 each for institutional orders of 20 or more. We have not yet determined pricing for individual units.

Ordered By

Name:
Title:
Institution:
E-mail:
Street:
City:
State:
Zip:
Telephone:

Shipping Address

Same As Ordered By:
Name:
Title:
Institution:
E-mail:
Street:
City:
State:
Zip:
Telephone:

Team Information

Team Name:
Main Color:
Other Color:

Size Distribution

Size	Quantity
Boys’ Regular (20-22"):
Boy’s Large (24-26"):
Men’s Small (28-30"):
Men’s Medium (32-34"):
Men’s Large (36-38"):

Shipping and Payment

Ship Via
Card Type:
Name on the card:
Card number:
Expiration date:

Restrictions

Purity Athletic will sell Viriguard units only to physicians or physical trainers at accredited public or private educational or correctional institutions. We require institutions to keep on file letters of consent signed by the parent or guardian of each minor fitted with a Viriguard, or, if the wearer has reached majority, by that wearer. We cannot accept responsibility for any injury arising from use of any items supplied, nor will we be party to any illegal use. By submitting this order you agree to hold Viriguard free of liability for injury resulting from the use of our product.

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