Instructions for off-line refill form:

When you click the link above, you will see a a small prompt with these same basic instructions.

1. Open the refill form by clicking the link above or right here.

2. Print the form by selecting 'File', then 'Print' from the new window's menu bar.

3. Complete the form

4. SIGN THE FORM

5. Fax the signed form to 1-203-662-0235