test-gf New Member Registration Name* First Last Email* Set your password* Enter Password Confirm Password Phone*Business Name* Website URL* Business Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you currently a member of any alliance or buying group?* Yes No Which buying group(s) are you currently a member of? 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.SignaturePlease sign using your mouse or touch-screen device. NOTE: Your IP address is stored with this submission for the purposes of fraud prevention.