Credit/Collection Department 13515 N Stemmons Freeway, Dallas, TX 75234 T: 1-800-372-3995
​Please fax completed form to 201-608-6854 Attn: Account Maintenance
Business Information
Legal Business Name
Business Start Date
Telephone
Fax
D/B/A
Tax ID (REQUIRED)
Legal Entity
☐ Corp ☐ Partnership ☐ LLC ☐ Sole Proprietorship
Billing Street Address
City
State
Zip
County
Have you ever done business with Nassau?
☐ No ☐ Yes Under Account Number(s): ​ Business Type
☐ MD ☐ OD ☐ DO ☐ Wholesale s☐ Other:
Email Address
If you wish to bill through a Buying Group, list it here
Buying Group Account Number
If you are part of a Doctor's Alliance, list it here
Doctors Alliance Verification Initials
(For Internal Use Only)
REQUIRED TO RECEIVE BUYING GROUP SPECIALS
REQUIRED TO RECEIVE DOCTORS ALLIANCE SPECIALS
REQUIRED TO RECEIVE BUYING GROUP SPECIALS
Are you an EYEMED Member?
☐ YES ☐ NO
Ship to Address
Storefront Name
Telephone
Fax
Street Address
City
State
Zip
County
Default Shipping Method
Stock & Contacts (REQUIRED)
☐​ ​UPS Next Day 10:30 ​☐ ​ UPS Saver ​☐​ UPS 2nd
​ ​ Day ​☐​ UPS Ground
☐ Courier if available : NAME_______________________________ CITY_______________________ STATE___________
Courier subject to Nassau Vision Group availability.
Lab Work (REQUIRED)
☐​ ​UPS Next Day
☐ Courier if available : NAME_______________________________ CITY_______________________ STATE___________
Courier subject to Nassau Vision Group availability.
Contacts
Corporate Officer/Owner
Telephone
Email
Accounts Payable Contact
Telephone
Email
Office Manager
Telephone
Email
Other ​(For Internal Use Only)
Total Estimated Sales Per Month
Stock Contacts Top Stock Lenses Used
Top Contact Lenses Manufacturer Used
Lab​
Top Materials Used
Top Contact Lenses Products Used
Uncut %
Assigned Stock List
Assigned Contact List
Progressive Of Choice
Finished %
Sales Representative
AR Of Choice
Assigned Lab List
Practitioner License
Name on License
License Type
☐ MD ☐ OD ☐ DO ☐ Other:
License State
License Number
Expiration Date
Bank Reference
Bank Name
Account
Bank Contact
Telephone
Fax
Email
Street Address
City
State
Zip
Trade References: List 3 ophthalmic references that business has had activity during the past year
Vendor
Vendor Account
Vendor Contact
Telephone
Vendor
Vendor Account
Vendor Contact
Telephone
Vendor
Vendor Account
Vendor Contact
Telephone
Agreement
To induce Nassau Lens Company to approve this Credit Application and in consideration of it so doing, we, the undersigned, do
hereby jointly, severally, and personally guarantee the above purchaser’s full performance of said purchase agreement and hereby
agree to indemnify Nassau Lens Co. against any and all damage, loss, expense (including attorney’s fees) and/or liability sustained by
Nassau Lens Co. by reason of or related to, the above purchaser’s failure to perform or to pay when due, charges incurred in
accordance with the above agreement. Nassau Lens Company may enforce this agreement against the undersigned or any of them,
jointly or severally, whether or not any action is ever taken by it against the above. Should this account have to be placed with an
outside collection service and/or attorney, the undersigned agrees to be responsible for an additional 25% of the amount outstanding
to cover costs of collection
Purchaser or extensions of additional credit to the Purchaser. I consent to Nassau Lens Co. attaining an individual credit report.
Authorized Signature​ MUST BE OWNERS SIGNATURE
Please initial this box if you are the OWNER of this
practice.
Date
Personal Guarantee For Business Name
Name
Social Security Number
Home Street Address
City
State
Zip
Telephone
Date
Resale Certificate
All accounts with shipping addresses located in the following states must attach state resale certification, not
sellers permits -Alabama, Arkansas, California, Hawaii, Idaho, Illinois, Kentucky, Louisiana, Mississippi, Missouri,
New Mexico, Nevada, Ohio, Oklahoma, South Carolina, Tennessee, Utah.
Credit Department Use
Sales Representative(s)
Account Number
Credit Limit
Credit Manager
Approved By
Date
Sales Consultant Representing Account
Sales Representative Name