Vision West Membership Application

This Vision West Membership Application is made and submitted by the applicant named below for the purpose of joining a membership organization administered by Vision West to participate in purchasing tools for ophthalmic products and services. In the event that Vision West 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 Vision West Membership Agreement, which is stated below.

Please check the agreement box the Principal owner.

*required field

 APPLICANT'S INFORMATION
Applicant Name* : 
Type* : 
Primary Practice Name* : 
Office Mgr Name : 
Business Address* : 
City* :   
State* :    Zip* :
Phone* : 
Fax* : 
Email* : 
Home Address* : 
Home City* : 
State* :    Zip* :
Home Phone* : 
Secondary Practice Name : 
Office Mgr Name : 
Business Address : 
City : 
State :    Zip :
Phone : 
Fax : 
Email : 
 
If you have more than one practice location, please indicate:
 
   
 BUSINESS INFORMATION
Business Type* : 
Corporation Name : 
Principal's Name* : 
Drivers Lic #* : 
Soc Sec #* :   (Enter as xxx-xx-xxxx)
Fed Tax ID* # :   (Enter as xx-xxxx)
State Lic # : 
# Yrs in Business* : 
# Yrs at Current Location* : 
Bank Name : 
 Bank Acct # : 
Branch Address : 
City : 
State :    Zip :
Contact Name : 
Phone : 
Credit Card : 
Credit Card Acct # : 
Exp Date : 
Trade Reference Name : 
Phone : 
Acct # : 
State/Group Affiliation : 
 
 NEW MEMBER SURVEY

Thank you for applying for membership with Vision West. We are pleased to include you as one of our valued members. In order to improve our services and better meet your needs, we ask that you complete the questions below.
 1. How did you hear about Vision West?
Name of Person Who Referred You :

 2. Why did you decide to join Vision West? (mark all that apply)
 Vendor Selection/DiscountsStraight-forward Billing Structure
 Education EventsVision West's Vendor Promotions
 Helpful Customer ServiceOnline Payment Convenience
 Support of Group or State AffiliationMember Resources (Newsletter, Business Services, etc.)
 3. What is your billing preference?
 
 4. What other buying groups & affiliations do you belong to?
 5. What services can Vision West provide for your practice?
  
   
MEMBERSHIP AGREEMENT
 
 ELECTRONIC MEMBER AGREEMENT

This application is subject to acceptance or rejection by Vision West in its sole discretion. Applicant hereby authorizes Vision West to obtain personal and/or business credit reports in connection with evaluating this Application and administering participation in the program. By completing the information below I (the undersigned) hereby agree to all the above terms and conditions of the Vision West membership agreement, and unconditionally personally guarantee performance of above terms and conditions by the primary practice named and any and all other accounts not specifically named in this agreement of which I have an ownership in, and payment of sums due there under in the event of default, and hereby waives any right to claim release or exoneration by reason of any modification, amendment, or extension or notice thereof. This guarantee shall be a continuing and irrevocable guarantee and indemnity to Vision West.
 

Principal Owner Initials* : 

 

2nd Principal Owner Initials : 

Principal Name* :    2nd Principal Name :
 By checking this box, I have read, understand and agree to the terms and conditions above.    By checking this box, I have read, understand and agree to the terms and conditions above.
       
This Application is Dated : 03/12/2010
Click the Submit button once to submit your completed application and we'll get back to you with your account details.