Apply for a Alternative Account

If you are an Eyecare Professional interested in having a representative contact you with information about our collections, please use the “CONTACT US” form found under the “ABOUT US” header.
If you are a customer ready to open an account with us, please fill out the form below and a representative will be in touch with you shortly with your account number.

Business Type:
Set as Primary Bill To?
AR, CA, IL, MO, NV, TN only - Exempt from sales tax?
If yes, please mail or fax Sales Tax Exemption Certificate

Bill through Buying Group or Co/Op?
Commerical References
Company Name
Address
Contact
Telephone
Banking References
Credit Card Information
Visa
Master Card


Option 1
I, the undersigned, authorize Alternative Eyewear and/or Plan "B" Eyewear to process a credit card payment on the 5th day of each month for this company's outstanding balance. I understand that in exchange for this pre-set payment date, this company will receive an additional 2% discount on that outstanding account balance.
Initials
Option 2
I, the customer, can call in when I would like Alternative Eyewear and/or Plan "B" Eyewear to process a credit card payment for me. I understand that I will waive the advantage for an additional 2% discount from Alternative Eyewear and/or Plan "B" Eyewear.

We hereby apply for credit and affirm financial responsibility, ability, and willingness to pay invoices in accordance with published terms. The above information is warranted to be true and complete. We hereby authorize you to verify and collection information on us, including but not limited to bank references, trade credit references, consumer and/or commercial credit reports. We agree to pay a monthly finance charge of the maximum applicable state rate on all past due balances. We agree to pay all costs of collection and litigation on this account in accordance with the laws of the Creditor's State of Incorporation We agree that all decisions with respect to the extensions or continuation of credit shall be in the sole discretion of the Creditor.