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:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   American Samoa Guam Marshall Islands Micronesia (Federated States of) Palau Puerto Rico U.S. Minor Outlying Islands U.S. Virgin Islands Northern Mariana Islands Armed Forces Americas AA Armed Forces Middle East, Europe, Canada AE Armed Forces Pacific AP   Other
Country:	USA OTHER
	(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)

Select Number of Employees Less than 50 50-99 100-499 500-999 1,000-4,999 5,000-9,999 Greater than 10,000

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?

Yes     No

Sign up for special offer alerts from select partners featuring the latest products and services you are interested in.

Yes     No

Download your FREE copy of the Online Fraud Report – 2008 Edition Today! This year's study found that online merchants estimate they lose 1.4% of their revenues to fraud or over $3.6 Billion in annual sales. Read about this and over 25 other fraud management benchmarks, trends and practices. Managing online fraud continues to be a significant and growing cost for merchants of all sizes. Total losses from online payment fraud in the U.S. and Canada have steadily increased as eCommerce continues to grow. Note: Offer Valid in the United States and Canada Only.

Free Merchant Account Quotes! Let the industry's top vendors compete for your business! Save time and money by comparing FREE multiple quotes for Merchant Accounts with only 1 form. All vendors are pre-screened and pre-qualified. There is No Cost and No Obligation. Submit a request now and get the best rates available! Note: Offer Valid in the United States Only.

Request your free On-Demand Webcast - Going Green: What's Good for the Environment is Good for Business. View this informative webcast featuring Gartner "Green IT / high performance workplace" analyst Mark Gilbert and Xerox VP of Environment, Health and Safety, Patricia Calkins. Discover how you can: Adopt policies that reduce waste, energy use, and greenhouse gasses while increasing efficiencies / ROI. Create an "early win" using Enterprise Content Management (ECM) solutions that will save your organization paper, energy, time, money, and waste. Employ some of the steps that Xerox and its customers have taken to dramatically reduce their carbon footprint and cut costs. Note: Offer Valid in the United States and Canada Only.

10% Off your next purchase at Office Depot! Sign up today for email alerts with great deals from Office Depot and get 10% off your next purchase. Quickly find the perfect office supplies, furniture or paper. Free Next Business day delivery on orders of $50 or more! * Some delivery restrictions do apply. Offer expires 09/20/2008. Note: Offer Valid in the United States Only. And offer excludes Technology Products.