Please fill in your existing account number for each vendor listed to transfer your billing to Preferred Select.             

As of ____ / ____ / _____    I, authorize my account to be billed through Preferred Select.
Date    

Preferred Select Account # _________________

Business Name : 

_______________________________

 Principle Name : 

_______________________________
Business Address :

_______________________________

 City, State, Zip : 

_______________________________
Business Phone # :

_______________________________

 Fax # : 

_______________________________
E-Mail : 

_______________________________

 Contact Name : 

_______________________________
Authorization Signature : 

_______________________________

 Title : 

_______________________________
Date : 

_______________________________

 Would you like to join
PS Contact Lenses?                       

Yes _______   No _______
Charmant Account Number : 

_______________________________

 Luxottica Account Number : 

_______________________________
Marchon Account Number : 

_______________________________

 Marcolin Account Number : 

_______________________________
Safilo Account Number : 

_______________________________

 Silhouette Account Number : 

_______________________________
Tura Account Number : 

_______________________________

 Viva Account Number :

_______________________________