US Safety Prescription Customer Profile Form (PDF)

Customer Profile – Prescription Safety Eyewear ProgramOriginal Document Revised Document Date:U.S. Safety Customer ID Number: __________________________(assigned by U.S. Safety)Company: (Customer Information)Name:Address:City, State, Zip: ,Contact:Phone: Ext: Fax:Email:U.S. Safety Will Bill To:Total Number of Employees:Distributors, please provide your billing office information.Name:Address:City, State, Zip: ,A/P Contact:Phone: Ext: Fax:Email:Tax Exempt ID #:(if applicable)E-Billing Contact:Phone:Invoice Type: (Select an Option) Purchase Order #:Billing Frequency: (Select an Option) Exp Date:Billing Terms: Net 30 PCard or Company Credit Card on file.Price Schedule : (Select an Option) Distributors, indicate “Special” if using line item pricing.Special Pricing/Instruction:Employee Co-Pays:Co-Pay Paid by: (Select an Option)Co-Pays Processed by: (Select an Option)Advance Payment can be made by Credit Card, Check or Money Ordermade payable to “U.S. Safety”. ** NO CASH, PLEASE **Check/Money Order = MAIL payment WITH order to U.S. Safety.Credit Card = Write CC information on order form and FAX to U.S. Safety.Optician Information:Office Name:Address:City, State, Zip: ,Phone: Ext: Fax:Email:Dispenser Tax ID#U.S. Safety Vendor Number:Note:Dispensing Information:Initial Setup:Service Method: (Select an Option)Frame Kit RequiredFitting Fee: $ Per Unit $ Per Hour No Charge Charge $Paid By: (Select an Option)Send Frame Kit To: (Select an Option)Send Order Forms To: (Select an Option)On-Site Schedule:Initial Number Of Order Forms Required:Sales Person:Company Name:Phone: Ext: Fax: Email:Page 1 of 38101 Lenexa Drive---P.O. Box 15965---Lenexa, Kansas 66285-5965TEL 913-599-5555 FAX 1-800-252-5002 RX FAX 1-800-428-7304e-mail: info@ussafety.comDIVISION OF PARMELEE INDUSTRIES, INC.

U.S. Safety Customer ID Number:Order Processing:Customer Profile – Prescription Safety Eyewear Program___________________________(assigned by U.S. Safety)Eligibility Rate: pair every Year Other:Orders Submitted By: (Select an Option)Hold Notifications To: (Select an Option) Via: (Select an Option)Orders Will Ship To: (Select an Option)Shipping Method: (Select an Option) Frequency: (Select an Option) Bin Number:Required information on orders (must be completed on Rx order form):Employee ID/Clock# Department # Employer Name Other:Using IOMS (Internet Order Management System) SEMS Employee List Updates:Using SEMS (Safety Eligibility Management System) Name: Phone:Email:Authorized Products:Company Pays Up To: $ (Select an Option)Company Pays 100% of (Select an Option)100% Advance Pay by: (Select an Option)Employee Upgrades: (Select an Option)(C = Company Paid, E = Employee Paid, N = Not Allowed) Please check ‘C’, ‘E’ or ‘N’ for each item.* Some states require that alicensed optician dispenseprescription glasses. Contact U.S.Safety for a list of states.: Options shownbelow in bold/italic are included inthe “Complete Price”.C E N Lens Materials C E N Coatings C E N Safety FramesGlass Scratch Resistant (Cr-39 Lens) Tier 1Cr-39 (Optilite) UV400 (Cr-39 Lens) Tier 2Polycarbonate** Anti-Reflective Multi-Coat Tier 3Anti-Fog High Performance Tier 4C E Lens Styles IR Shade (SV & Progressive) Tier 5* Single Vision Ultra Hard Coat Tier 6* Bifocal Tier 7* Trifocal C E N Tints Tier 8Double Segment Solid Tier 935mm/Full Width Bifocal Gradient Tier 10PhotochromicSpecial Frame ListC E N Progressive Lenses Polarized (see attached)Level 1(Standard)Level 2SideshieldsLevel 3 C E Special OptionsLevel 4 * Roll & PolishLevel 5 * High Index Lens(Select an Option)Other (see below) * Aspheric Lens* Item may be required by prescription. ** Polycarbonate is the most impact resistant lens material available.Program Notes:For product and service updates, please visit www.ussafety.com and click on “Prescription”.See Page 3 for additional notes (if required)Page 2 of 38101 Lenexa Drive---P.O. Box 15965---Lenexa, Kansas 66285-5965TEL 913-599-5555 FAX 1-800-252-5002 RX FAX 1-800-428-7304e-mail: info@ussafety.comDIVISION OF PARMELEE INDUSTRIES, INC.

Customer Profile – Prescription Safety Eyewear ProgramAdditional Notes:Page 3 of 38101 Lenexa Drive---P.O. Box 15965---Lenexa, Kansas 66285-5965TEL 913-599-5555 FAX 1-800-252-5002 RX FAX 1-800-428-7304e-mail: info@ussafety.comDIVISION OF PARMELEE INDUSTRIES, INC.