Combined Vendor Form

Pivotal Group will submit this form to the Vendor you select. We are not responsible for the information contained within the form or for any followup information. If you are attempting to sign up for the lab or stock program, please fill out their respective forms on the applications page.

Applicant Name

First Name

Last Name

Applicant Email

Applicant Phone

(###)

###

####

Applicant Role/Description

Business Name (DBA)

Business Legal Name

Primary Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Office Phone

(###)

###

####

Staff-Accessible Email

Programs I Wish to Sign up For:

(Select one or multiple)

Eight to Eighty Eyewear

Art Optical

Is Your Office Currently Open and Operating?

Trade Reference 1 Company Name

Trade Reference 1 Account Number

Trade Reference 2 Company Name

Trade Reference 2 Account Number

Trade Reference 3 Company Name

Trade Reference 3 Account Number