New Customer Form New Customer Form Business Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Name(s)*Email for Statements* Email for Shipping Notifications* LMS that Customer Uses*Does Customer Use Opticom?*Total Pairs Per Day the Lab is Producing:*ProductsWhich products do you plan to purchase from TOG USA? Select All 1.50 Clear SFSV UC 1.50 Clear SFSV HC 1.50 Bluloc SFSV HC 1.50 Transitions Gen 8 Gray SFSV HC 1.50 Transitions Gen 8 Brown SFSV HC 1.53 Trivex Clear SFSV HC 1.53 Trivex Clear SFSV UC 1.53 Trivex Super AR FSV HC 1.53 Trivex Bluloc SFSV HC 1.53 Trivex Transitions Gray SFSV HC 1.53 Trivex Transitions Brown SFSV HC 1.60 Tribrid Clear SFSV UC 1.60 Tribrid Clear SFSV HC 1.60 Tribrid Bluloc SFSV HC 1.60 Tribrid Transitions Gen 8 Gray SFSV HC 1.60 Tribrid Transitions Gen 8 Brown SFSV HC 1.60 Clear SFSV UC 1.60 Clear SFSV HC 1.60 Bluloc SFSV HC 1.60 Transitions Gen 8 Gray SFSV HC 1.60 Transitions Gen 8 Brown SFSV HC 1.67 Clear SFSV UC 1.67 Clear SFSV HC 1.67 BluLoc SFSV HC 1.67 Transitions Gen 8 Gray SFSV HC 1.67 Transitions Gen 8 Brown SFSV HC 1.74 Leafeco Clear SFSV UC 1.74 Leafeco Clear SFSV HC 1.74 Leafeco Bluloc SFSV HC 1.74 Leafeco Transitions Gray SFSV HC 1.74 Leafeco Transitions Brown SFSV HC Any Additional CommentsShipping*Please check one for default Ground 2nd Day Air Next Day Air Next Day Air Saver Other (List Below) Please list other shipping requestedOther Comments Download Credit Application Need Assistance?Contact Us
