Frame, Spectacle Lens, or other Partner Registration Form


Thank you for your interest in Eyefinity. Please complete the form below if you would like more information on joining Eyefinity as a partner.

Important: Partners already integrated with Eyefinity do not need to fill out this form.
                                               
Address Information:
 
Company Name * 
Address line 1 * 
Address line 2    
City  *  State *  Zip code * 
 
Contact Information:
 
Business Contact Name: * 
Business Contact Phone: * 
Business Contact Email: * 
Technical Contact Name: * 
Technical Contact Phone: * 
Technical Contact Email: * 
 
How did you hear about Eyefinity (choose one)? *
 
Promotional Mailer
Word of Mouth / Friend
Received a Phone Call
Advertisement in Trade Publication
Received inquiry from eyecare practice
Trade Show  (please specify)
Other  (please specify)
 
Business Information:
 
A.) # of Employees: *
B.) # of Customers (Eyecare Practices): *
C.) # of frames sold per month: *
D.)

Is your company owned in part or full by an Ophthalmic Insurance Company,
or any organization affiliated with a dispensary or retail outlet? *
  No Yes  
 
 
* Indicates a required field