CUSTOMER NEW ACCOUNT FORM

CUSTOMER NEW ACCOUNT FORM
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Business Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Website
Instagram (@)
Tax Id# or SSN
Number of Years in Business
Owner Name

First NameLast Name
Owner Email
example@example.com
Buyer Name (If Different)

First NameLast Name
Buyer Email
example@example.com
Accounts Payable Name (If Different)

First NameLast Name
Accounts Payable Email
example@example.com
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address (If Different)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Dropship Address (If Any)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are You A Member Of A Buying Group?
Buying Group Acct#
Please list three of your best selling independent eyewear brands. This will help us better understand what works well in your practice and allow us to make more informed recommendations on future product mix.
We're a New Practice
1. Brand You Carry
2. Brand You Carry
3. Brand You Carry
Should be Empty: