Please provide all the information requested.
New Optometrist Registration
Username:
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Password:
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Confirm Password:
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Your Name:
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Company Name:
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DBA Names (Please list all that apply):
Street Address:
(Line 1)
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(Line 2)
City:
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State:
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Zip:
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Phone:
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Ext:
Fax:
Email:
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Insurance Agreement: Any claims for loss or damage must be made within 30 days of the date of request for pick up. All deliveries are covered for a maximum of $100.00 in value. OTD is not responsible for any damage or breakage if item is not properly packaged and labeled correctly.
I have read and agree to the above terms
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