Indesign Eyewear - Registration

We only supply optometrists.

Please complete the following information in order to register as a stockist and view our pricing.

Please note: Fields marked with a ( * ) are required

Company Details

* Company:

* Practice No. or Company Registration No. :

* Are you an optometrist?

Yes

Vat No:

*Login Email Address:

Same as Login Email Above?

* Accounts Email Address:

Same as Login Email Above?

Buyer's Email Address:

Website Address:

* Telephone No:

Cellular No:

Your Details

* First Name:

* Surname:

* Password:

* Confirm Password:

Physical Address

* Physical Address:

* City:

Postal Code:

* Province:

* Country:

Postal Address

Same as Physical Address Above?

* Postal Address:

* City:

Postal Code:

* Postal Province:

* Postal Country:

Newsletter

* Would you like us to email you our newsletter containing product information?

Yes