Auto Draft - Pivotal Group

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*

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

Billing Info

Bank Name*

Bank Account Number*

Routing Number*

Account Type*

Checking
Savings

Enrollment in auto-pay via ACH withdrawal*

Having a Pivotal Lab account requires enrollment in auto-pay via ACH withdrawal. Clients will be provided statements several days prior to automatic withdrawal to allow time to review and/or dispute any unrecognized or incorrect charges. By checking this box, you acknowledge and agree to being enrolled in auto-pay. Accounts may be managed and charged by Pivotal Group, or their partner company Optic Ascent LLC. By signing, you acknowledge Pivotal Group and/or Optic Ascent will use this bank information to process payments for these lab services. You may request changes to the payment information on file at any time be contacting Pivotal Group at least 72 hours before payment due date. Any changes to payment info on file will incur a $1.00 application fee to verify that the information provided is valid. You acknowledge you will be responsible for any fees assessed against Pivotal Group if this information results in an unsuccessful ACH withdrawal.

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.

PLN – EDO Lab Application.

PLN Application Form – EDO

Billing Info