Membership Application

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MEMBERSHIP APPLICATION

This Vision West, Inc. (VWI) Membership Application (Application) is made and submitted by the applicant named below (Applicant) for the purpose of joining a membership organization administered by VWI to participate in purchasing tools for ophthalmic products and services. In the event that VWI approves the Application, Applicant's membership in the organization, as well as any purchases made pursuant thereto, shall be governed by the terms and conditions set forth in the VWI Membership Agreement, which is available from VWI.

Applicant's Name:	(Check one) OD MD Optician Vendor Other
Primary Practice Name:
Office Manager:
Business Address:
City:	State: Zip:
Phone:	Fax:
Email:
Home Address:
City:	State: Zip:
Secondary Practice Name:
Office Manager:
Business Address:
City:	State: Zip:
Phone:	Fax:
Email:
If you have more than one practice location, please indicate:
Combine all purchases on one statement and send to primary location , or
Create individual accounts for each location and send statements to each practice address.
(Check one) Partnership Proprietorship Corporation (List name)
Partner, Owner or Officer's name:	DL #:
Fed Tax ID#:	SSN #:
State License #:
Length of time in business:
Length of time at current location:
Bank Name:	Account #:
Branch Address:
City	State: Zip:
Contact Person:	Phone:
Major Credit Card:	MasterCard VISA Other
Account #:	Exp date:
Trade Reference:
Phone:
Account #:
TERMS OF APPLICATION: This application is subject to acceptance or rejection by VWI in its sole discretion. Applicant represents that the information provided on this Application is true and complete. Applicant hereby authorizes VWI to obtain personal and/or business credit reports in connection with evaluating this Application and administering participation in the program. Applicant has read and agrees with the provisions of this Application and the terms and conditions of the VWI Membership Agreement. If Applicant is not an individual, then the person signing below represents and warrants that he or she is authorized to sign on behalf of the entity that is the Applicant.
By
Print Name (Signature)
Title	Date
I hereby agree and accept the terms and conditions of the membership agreement FOUND HERE

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