Pivotal Group Application (OA)

Applicant's Name*

First Last

If you are filling out the application, please use YOUR name.

Applicant's Email*

Applicant Phone Number*

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*

Office Email

For general office correspondences

Is your office currently open?*

Yes
No, not yet

Proposed Open Date*

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

Website URL*

If you do not have a website, please place "N/a" in this field.

Set your password*

Enter Password Confirm Password

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

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.

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.

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