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SALES CONSULTANTS WHERE APPLICABLE *
BUSINESS ADDRESS
PRIMARY OPTICAL CONTACT #1
PRIMARY OPTICAL CONTACT #2
BILLING CONTACT NAME
IS YOUR BILLING ADDRESS DIFFERENT THAN YOUR BUSINESS ADDRESS?
BILLING ADDRESS

E-statement email

PREFERRED PAYMENT METHOD *

Self-Managed Web Payments are online payments via SpecCheck. Auto Payments are payments through COL via CC/ACH

Self-Managed Web Payments are online payments via SpecCheck. Further payment setup information will be sent to you upon completing this New Account Form.
Auto Payments are COL Lab payments via CC/ACH. Further payment setup information will be sent to you upon completing this New Account Form.
ARE YOU A PROVIDER FOR ANY OF THE FOLLOWING? IF YES, SELECT ALL THAT APPLY.
ORDER/JOB TYPE
WHICH SOFTWARE ARE YOU CURRENTLY USING TO ORDER ONLINE?
ARE YOU INTERESTED IN RECEIVING INFORMATION ON ELECTRONIC ORDERING? *

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