Account Application

Account Application

If you are an Eye Care professional, please complete and submit form and a representative will contact you.
Select Type
Account Number (if reactivating)
Owner Name

FirstLast
Title/Position
Business Email
example@example.com
Contact Name

FirstLast
Contact Email
example@example.com
Business Name
Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Shipping Address (if different than billing)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Type of Business
Alliance Member?
Alliance Member ID
Billing through Buying Group?
Buying Group Member ID
Tax Exempt? (AR, CA, IL, MO, NV, TN only)
If yes, please upload certificate (AR, CA, IL, MO, NV, TN only)

Cancelof
Tax ID
A/P Contact
A/P Email
example@example.com
Enroll in E-Statements?
Send Auto Deduct Form?
Applicant Name

First NameLast Name
Applicant Signature
Date

MonthDayYear
Date
Should be Empty: