Fill out the form below to register for Optima's Online Consumer Referral Program. (Note: All fields must be filled in.) Your First Name Your Last Name Store Contact's Name Store Name (Retail Location) Address City 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 Zip E-mail Address Lab You Usually Order Lenses From Lab Address City 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 Zip Are you currently selling Optima lenses (HyperIndex® 1.60/1.66/1.74, HyperView® 1.66 or RESOLUTION™)? Yes No How did you learn about our web site or Online Consumer Referral Program? Trade Magazine Ad Web Search Engine Customer Trade Press Lab Rep Other (please fill in) NOTE: You will be notified by e-mail once your location is accepted into our referral program.
Fill out the form below to register for Optima's Online Consumer Referral Program. (Note: All fields must be filled in.)
Your First Name Your Last Name
Store Contact's Name
Store Name (Retail Location)
Address
City 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 Zip
E-mail Address
Lab You Usually Order Lenses From
Lab Address
Are you currently selling Optima lenses (HyperIndex® 1.60/1.66/1.74, HyperView® 1.66 or RESOLUTION™)? Yes No
How did you learn about our web site or Online Consumer Referral Program? Trade Magazine Ad Web Search Engine Customer Trade Press Lab Rep Other (please fill in)
NOTE: You will be notified by e-mail once your location is accepted into our referral program.
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