Enroll

PracticePlus Enrollment Application

Contact Name*
Title*
Primary Phone*
Submitter Email Address*
DBA*

Doing Business as Name
LEN*

Legal Entity Name associated with your EIN. Please reference your tax forms if uncertain
EIN (Tax Identification #)*

EIN must be 9 digits / no hyphens please. Please reference tax forms if you are uncertain. NOTE: For practices with multiple locations operating under multiple EIN’s, please submit each via this form separately
Primary Practice Owner Name*
First Last
Primary Owner Email Address*

This is the email that will receive all program communications
Primary Practice Address*
Primary Practice Address Line 1 * Primary Practice Address Line 2 * Primary Practice Address City * Primary Practice Address State * Primary Practice Address Postal Code (Zip Code) *
Hidden
Office Mailing Address (If Different)
Street Address City State / Province / Region ZIP / Postal Code Country
Invitation CC

Email address of additional practice staff member/person you would like to be included to ensure a quick enrollment
Additional Practice Location Address(s)
Please add the Address, Suite, City, State, Zip for EACH location that shares the same EIN. One primary location will be established per EIN. Points earned from other locations sharing the same EIN will roll up through primary location.
Additional Practice Locations*
Name Street Address City State Zip Code
Wholesale Laboratory Suppliers
Wholesale Laboratory Suppliers**
Name City State Lab Account #

Note: You MUST include the lab name and associated lab account #’s for all participating lab accounts associated with this practice address and any additional practice locations listed. Missing details will result in processing delays
W-9 Form Submission
A W-9 Form signed by the Practice Owner is required as part of the enrollment process. Your enrollment will no be fully processed until we receive your completed W-9 form.
Fax Information
Please fax the completed W-9 form to - 1-866-280-4586
Group Affiliation (only one please)
Group Affiliation
- C&E Vision
- ClubZero
- IDOC
- PERC
- Vision Source
- Vision Trends
- CBP

Name	Street Address	City	State	Zip Code

Name	City	State	Lab Account #

PracticePlus Enrollment Application

Additional Practice Location Address(s)

Wholesale Laboratory Suppliers

W-9 Form Submission

Fax Information

Group Affiliation (only one please)