IOLAB-Working w/ Independant ECP's

To Request an Account with IOLAB.org please fill out the form below and we will contact you OR Print one off and fax back to appropriate Lab- CLICK HERE FOR .pdf VERSION

PLEASE SELECT LABORATORY OF CHOICE: Indiana Ophthalmics Illinois Ophthalmics

BUSINESS INFORMATION:

Legal Business Name:

D/B/A (doing business as):

Telephone Number:

FAX:

Federal ID or SS Number:

Business Start Date: -if before 1999 enter it here:

Accnt. Payable Contact Name: Accnt.Ph: Expected Monthly Sales:

BILLING ADDRESS:

Street Name & Number: Country: City:

State: ZIP:

shipping address:

Same As Above: YES: NO: (if not please fill out below)

Street Name & Number: Country: City:

State: ZIP:

Practitioner license information:

Practitioner Name: License Number: License State:

Expire Date:

Choose One: | OD | MD | DO | Optician | Industrial | Other

trade references:

(Please list 3 credit references in the industry to whom you have sent substantial business in the past year)

1)Account Name & Number: Name: Number: Address: Phone:

2)Account Name & Number: Name: Number: Address: Phone:

3)Account Name & Number: Name: Number: Address: Phone:

Terms & Conditions:
By clicking REQUEST MY APPLICATION you agree that all the information you have provided is true and without fault. You certify that you hold a valid sellers permit and that goods will be resold by me in the form of tangible persoanl property: Provided, however, that in the event any such property is used for any purpose other than retention, demonstration, or display while holding it for sale in the regular course of business, it is understood that I am required by the Sales and Use Tax Law to report and pay the Tax, measured by the purchase price of such property. Confirm Read: