Become a Kmars Customer Open a K-Mars Optical Account New Account Information and Credit Review "*" indicates required fields Step 1 of 2 50% Applicant’s Name* First Payment Method* Company Check Credit Card Company Name* Billing Address* Street Address City State / Province / Region ZIP / Postal Code Email* Phone*Business Type* Sole Proprietor Partnership Corporation LLC Owner’s /Partner’s Name(s)* Business License #* Soc. Sec or FEIN#* State Sales Tax ID#* Number of Years in Business*Accounts Payable Contact:* * Ship To Address if different than the billingPlease list addresses. Please advise if individual account number or individual drop ship desired*Business NameAddressCityZipcode Add RemoveBank DetailsBank Name* Contact Name* Account No* Please provide 3 Trade References (One of the references must be an Optical Lab or Lens SupplierName* Phone*Account No*Name* Phone*Account No*Name* Phone*Account No*I hereby certify that the above information is true and correct and is provided for the purpose of obtaining credit. I,* hereby authorize K-Mars Optical. to use the information provided here to contact the sources listed above to verify all the necessary information about my business.Owner’s signature*Date* MM slash DD slash YYYY Owner’s name* First (no titles please)Owner’s social security number How did you hear about us? Mail Email Telemarketing Referral Name of Referral Date* MM slash DD slash YYYY Company Name* Card Holder's Name* First Credit Card Billing Address* Street Address City State / Province / Region ZIP / Postal Code This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name I,Credit Card Holder* (Please Print Credit Card Holder Name) Authorize K-Mars Optical to charge the above mentioned card for purchases made byPrint Company Name* I authorize K-Mars Optical to maintain my credit card account number on file for all future purchases. I will notify K-Mars Optical of any changes.Signature of Credit Card Holder*
