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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 *

SpecCheck Lab Pay Portal - Auto Pay are online payments via SpecCheck. Auto Payments are payments through COL via CC/ACH

SpecCheck Lab Pay Portal - Auto Pay 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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