safety_enrollment

The Eye and Vision Safety Plus Program Enrollment Form

Company Name*

Contact Name*

Address*

Phone*

City*

State*

Zip*

Fax

Email*

Number of Employees*

This company would like to enroll in The Eye and Vision Center's Safety Plus Program.
We have chosen the following payment option:

The Company will pay the basic package price ($85 or $120) for all employees, and our employees will pay for any upgrades to the package price. The Company will pay the basic package price ($85 or $120) for all employees plus the upgrade charge for the upgrades indicated below. All employees will pay for their own safety glasses.

Note: If the company will pay for any amount of the employee's safety glasses, please fill out the separate payment agreement form.

Please specify your company's preferences for the following options:

Sideshields:

removable allowed permanent required

Tinted Lenses: