Eyecare Business Free Subscription

	*Eyecare Business* is free to qualified professionals. Summary Description
	To apply for a FREE subscription to *Eyecare Business*, please answer ALL of the questions on the form below.
	The publisher determines qualification and reserves the right to limit the number of free subscriptions.
	Geographic Eligibility: USA

1.	*Do you wish to receive a FREE subscription to Eyecare Business?*

Yes No

First Name:
Last Name:
Job Title:
	(Ex: Director, Vice President, Project Manager, etc.)
Company:
	(Please provide your Company Name in full: abbreviations could disqualify you)
Street Address:
Division/Mail Stop:
City:
State:
Country:
	(Note: If your country is not listed above, subscriptions are not currently available at your location.)
Zip/Postal Code:
Business Phone:
Business Fax:
Email Address:
	(Note: Valid email address is required or you could be disqualified.)

What is the approximate number of employees in your company? (select only one)

Yes, please auto-fill my contact information for other publication qualification forms.

2.	May we contact you via email?

Yes No

3.	May we contact you via email on behalf of ophthalmic industry on topics pertinent to you?

Yes No

4.	May we contact you via fax?

Yes No

5.	Please check the ONE category that best describes your business/professional activity: (select only one)

DISPENSING OPTICIAN OPTOMETRIST cont.

Self-employed/owner Independent affiliated with retail corporation

Employee of retail corp(chain) Employee with retail corporation

Employee of independent optician Employee of O.D.

Employee of independent O.D. Employee of M.D.

Employee of independent M.D. Other optometrist (please specify)

Other dispensing optician (please specify)

OPHTHALMOLOGIST

OPTOMETRIST OPTICAL LAB/WHOLESALER

Solo practice EXECUTIVE/BUYER AT CHAIN HEADQUARTERS

Group practice OTHER (please specify)

Corporate franchise

6.	What is the wholesale price range of the majority of the eyeglasses sold at your business? (select one only)

Over $150 $51 - $100

$100 - $150 Under $50

7.	At your practice, of the spectacle lenses you dispense, what percentage are A/R coated?

%

8.	What are the lens processing capabilities on-site at your business? (select all that apply)

Finishing (edging) Surfacing

Casting None

9.	Do you buy, specify, approve or influence the purchase of contact lenses?

Yes No

10.

Do you fit contact lenses?

Yes No

11.

In lieu of a signature, we require a personal identifier. To verify that you submitted this application please enter below in what state were you born:

Would you like to receive EMAIL notices of other print or online publications, and other relevant offers from TradePub.com?

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What category best describes your JOB FUNCTION? (select only one)

Please specify for Other:

What is your primary BUSINESS ACTIVITY at this business location? (select only one)

You may receive emails from Digital Healthcare & Productivity (a division of CHI) regarding your subscription. If you do not want to receive this, please check No.

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In lieu of a signature, our audit bureau requires a personal identifier (to be used for audit verification only): What is the first letter of the month you were born?

* Note that a valid email address is required to fulfill your request. Please verify that the email and mailing address you provided are accurate before hitting the submit button.

* The publisher reserves the right to limit the number of free subscriptions and/or reject requests based on information provided.