Independent Ophthalmic Network | Online Buying Group Application Form

" A Focus on Co-Operation . . . "

Buying Group

Online Buying Group Application Form

Directions: Please complete the application form below. Mandatory fields are marked with an asterix. Once complete, click the Submit Application Form button at the bottom of the page. This form is only for current members of ION - if you are not a current member, please first apply for membership.

Name:

Full Name : *

Address of Practice:

Street: *

Suburb: *

Post Code: * eg. 4000, 4004

State: * eg. QLD, NSW, CA

Country: * eg. AU, USA

Contact for Correspondence:

Phone: * eg. 01 2345 6789

E-Mail: * eg. name@domain.com

What do you want to purchase?

What is your timeframe for purchasing?

I am already an ION Member

I am not an ION Member, please join me up!

Street: *
Suburb: *
Post Code: *	eg. 4000, 4004
State: *	eg. QLD, NSW, CA
Country: *	eg. AU, USA