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* {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…
