• Important Notice

  • If you are paying for any portion of your eyewear with a credit/debit card you must obtain a Secure Credit Card ID number to be used in place of the actual credit card number. This procedure is to protect your card number from theft or fraudulent use. Click here to obtain your Secure Credit Card ID number.

Client Account Number:   0005000
Secure Credit Card ID#:
Credit Card Type: VI,MC,AX,DI
Credit Card Expiration Date: MM/YY
Employee First Name:   *
Employee Last Name:   *
Supervisor/Contact Phone:   *
Employee Number:  
Department #:  
Requisition #:  
Employee Phone:  

To print a blank form please click the view e-form button.