New Vendor Sign-Up Form

Miraflex does not sell retail or compete with retailers on any level.
If you are a parent looking to purchase a safe frame for your child, please go to our
store locator and enter your zip code to find the nearest retailer.

Step 1 of 3

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Basic Account Details
Account Point Of Contact*
First Last

The Name of the person who will be placing orders with Miraflex.
Point of Contact Phone Number*
The phone number for direct communication to the account Point of Contact.
Point of Contact Email Address*

The Email address used by the account Point of Contact.
Doctor(s) or Sr. Management Name
First Last

The name of the Doctor or Sr. Management responsible for managing the daily activities of your practice.
Doctor(s) or Sr. Management's Professional Title*
The professional title of the Doctor or Sr. Management responsible for managing the daily activities of your practice.
Doctor(s) or Sr. Management Email Address*

The Email address used by the Sr. Mangegment Staff.
Point of Contact Phone Number*
The phone number for direct communication to the Sr. Mangegment staff.
Business/Practice Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is your Busisness Tax Exempt*
- Yes, our business is Tax Exempt
- No, we do not have a Tax Exempt status
We will use this information to determine if additional information is required on your customer profile.
Resale Certificate Number
The IRS issue Resale Certificate number for your practice.
Are you applying for a line of Credit?*
- Yes, We would like to establish a credit accout with Miraflex
- No, We do not need a line of credit.
We will use this information to determine if additional information is required on your customer profile. If you are applying for a line of credit selecting "Yes" will display the credit application.
Would you like your Business/Practice to be listed our website as an authorized dealer?
- Yes, Please add our information to the official Miraflex website.
- No, Do not add us to the official Miraflex website

Business/Practice Information to be listed on Miraflexglasses.net
Information specific business/practice that will be shown on MIraflexglasses.net
Name Of Practice
The Name of your practice.
Practice Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Practice Email Address*

This address will be viable to all Miraflex.com users searching for local Miraflex dealers.
Primary Practice Phone Number*
This phone number will be viable to all Miraflex.com users searching for local Miraflex dealers.
Primary Practice Fax Number
This Fax number will be viable to all Miraflex.com users searching for local Miraflex dealers.
Practice Website

This web address will be viable to all Miraflex.com users searching for local Miraflex dealers.

This section will guide you through the Miraflex credit application process. We will collect the required information to review your application. ***Completion of this section does not guarantee acceptance***
Your Contact Information
Information specific to the person(s) appling for the line of credit.
Applicant Name*
First Last

The name of the person(s) applying for the line of credit.
Company/Practice Name*
The legal name of the company or practice you reprecent.
Company/Practice Phone Number*
Company/Practice Fax Number
Company/Practice Email Address*
Company/Practice Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Requested Line of Credit Amount
Please enter a value between 200 and 5000.
***EDIT ME WITH INFO CONCERNING LINES OF CREDIT*** ***CONFIGURED FOR A 5K Limit***
Busisness References
Note: To ensure this application is processed successfully, please confirm with your references before providing their information on this form. Some businesses will not provide any credit references to 3rd party companies.
Company Name
The company name of your first reference.
Company Address
Street Address City State / Province / Region ZIP / Postal Code Country

The company address of your first reference.
Phone Number*
The phone number of your first reference.
Fax Number
The fax number of your first reference.
Email Address

The Email address of your first reference.
Company Name
The company name of your second reference.
Company Address
Street Address City State / Province / Region ZIP / Postal Code Country

The company address of your second reference.
Phone Number*
The phone number of your second reference.
Fax Number
The fax number of your second reference.
Email Address

The Email address of your second reference.
Company Name
The company name of your third reference.
Company Address
Street Address City State / Province / Region ZIP / Postal Code Country

The company address of your third reference.
Phone Number*
The phone number of your third reference.
Phone Number*
The phone number of your third reference.
Fax Number
The fax number of your third reference.
Email Address

The Email address of your third reference.
Agreement
All Invoices are to be paid 30 days from the date of the invoice.*
- I Agree
Claims arising from invoices must be made within 7 working days.*
- I Agree
By submitting this application you authorize Miraflex USA to make inquiries into the business references you have supplied.*
- I Agree
Acknoledgement
Name*
First Last
Date*
Title*
Comments
This field is for validation purposes and should be left unchanged.

New Vendor Sign-Up Form

Step 1 of 3

Basic Account Details

Business/Practice Information to be listed on Miraflexglasses.net

Your Contact Information

Busisness References

Agreement

Acknoledgement