Education
Our Relationships
Our Prices
About
More
Contact
Contact
Log In
Log Out
Become a Member For Free
Members Area

Select Page

Pivotal Membership and Lab Application.

Please only fill out the application below to join Pivotal group and open a lab account. There are no fees to join, or obligations to order when opening a lab account.

Please fill out one application per location.

All sensitive data requested through this application is protected using a secure connection and military-grade encryption.

This application will require approximately 5 minutes to complete. You will need the following information:

Names & emails of all important contacts to be associated with this lab account.
Office contact & shipping information.
Business information, including legal name, DBA, and UPS-recognized address.
Financial information to be put on-file with this account.
A signature from an owner or authorized user of the bank account on-file.

Pivotal Lab Application Form

Applicant's Name*
First Last
If you are filling out the application, please use YOUR name.
Applicant's Office Role*
What is your role in this office?
Are you the business owner?*
- Yes
- No
Office Owner's Name*

If same as above, just place it here again
Business Name (DBA)*
Business Legal Name*
Office Phone Number*
Is your office currently open?*
- Yes
- No, not yet
Proposed Open Date*
MM slash DD slash YYYY
Do you have a proposed location address?*
- Yes
- No, not yet
Location of Proposed Office*

No address yet? That's Ok. Please indicate the City, State you are planning to open your new office
Proposed Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Business Address*
Street Address City State ZIP Code
EXACT Shipping Address (per UPS)
Same as previous

Street Address Address Line 2 City State ZIP Code
Website URL*

If you do not have a website, please place "N/a" in this field.
Applicant's Email*

This will act as your username for the www.trypivotal.com website.
Set your password*
Enter Password Confirm Password

Set your password for access to the www.trypivotal.com website
Billing Email*

Statements and billing correspondences will be sent here.
Are you currently a member of any alliance or buying group?*
- Yes
- No
Which buying group(s) are you currently a member of?
What Pivotal Programs are you interested in?*
- Lab Services
- Stock Lens Services
- Equipment
- CC Processing
- Contact Lens Discounts
- Educational (opt-out, OON, profitability, etc)
- Other
- I'm not sure yet
Membership Agreement*
- I agree to Pivotal Group's Membership Agreement
Non-Disclosure Agreement*
- I agree to Pivotal Group's Non-Disclosure Agreement
I understand that the Pivotal Lab programs require enrollment in autopay via ACH, and Pivotal Group will reach out to me to obtain this information before finalizing my lab account.*
- I acknowledge
Declaration of Non-Fraudulent Application*
- I declare under penalty of perjury (under the laws of the United States) that I am an optometry clinic or or independent optical dispensary, and that all information submitted with this application is accurate and true. I confirm I have the authority and permission to register this business for a new PLN account.
Electronic Signature*

Must be signed by the business owner or authorized user. NOTE: Your IP address is stored with this submission for the purposes of fraud prevention.
Signature
Please sign using your mouse or touch-screen device. NOTE: Your IP address is stored with this submission for the purposes of fraud prevention.

Phone: (800) 819-2084 | Email: support@trypivotal.com

Address: 1508 Dessau Ridge Ln Ste. 806 | Austin, TX 78754

© 2024 Pivotal Group | Privacy Policy