Eyecare Business Free Subscription

	*Eyecare Business* is free to qualified professionals. Summary Description
	To apply for a FREE subscription to *Eyecare Business*, please answer ALL of the questions on the form below.
	The publisher determines qualification and reserves the right to limit the number of free subscriptions.
	Geographic Eligibility: USA

1.	*Do you wish to receive a FREE subscription to Eyecare Business?*

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First Name:
Last Name:
Job Title:
	(Ex: Director, Vice President, Project Manager, etc.)
Company:
	(Please provide your Company Name in full: abbreviations could disqualify you)
Street Address:
Division/Mail Stop:
City:
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Business Fax:
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What is the approximate number of employees in your company? (select only one)

Yes, please auto-fill my contact information for other publication qualification forms.

2.	May we contact you via email?

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3.	May we contact you via email on behalf of ophthalmic industry on topics pertinent to you?

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4.	May we contact you via fax?

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5.	Please check the ONE category that best describes your business/professional activity: (select only one)

DISPENSING OPTICIAN OPTOMETRIST cont.

Self-employed/owner Independent affiliated with retail corporation

Employee of retail corp(chain) Employee with retail corporation

Employee of independent optician Employee of O.D.

Employee of independent O.D. Employee of M.D.

Employee of independent M.D. Other optometrist (please specify)

Other dispensing optician (please specify)

OPHTHALMOLOGIST

OPTOMETRIST OPTICAL LAB/WHOLESALER

Solo practice EXECUTIVE/BUYER AT CHAIN HEADQUARTERS

Group practice OTHER (please specify)

Corporate franchise

6.	What is the wholesale price range of the majority of the eyeglasses sold at your business? (select one only)

Over $150 $51 - $100

$100 - $150 Under $50

7.	At your practice, of the spectacle lenses you dispense, what percentage are A/R coated?

%

8.	What are the lens processing capabilities on-site at your business? (select all that apply)

Finishing (edging) Surfacing

Casting None

9.	Do you buy, specify, approve or influence the purchase of contact lenses?

Yes No

10.

Do you fit contact lenses?

Yes No

11.

In lieu of a signature, we require a personal identifier. To verify that you submitted this application please enter below in what state were you born:

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What is the approximate number of employees in your company? (select only one)

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Which of the following is closest to your job function? (select only one)

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What is the number of employees in your entire organization? (select only one)

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Do you currently conduct transactions (sales, form completion, etc) on your Web site? (select only one)

Which of the following are part of your customer service offerings? (select all that apply)

Click to Call Contact Us form

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