Question Title * 1. Please fill out the information below so that we have your correct and current information. Name Home Address City/Town State ZIP Cell Phone Email Address Question Title * 2. Please fill out the information for your primary practice location. Primary Office Name Address City/Town State ZIP Office Phone Number License Number Question Title * 3. For your primary practice location check all that apply to you for this location. Solo owner of a practice with a dispensary Solo owner of a practice without a dispensary Owner in a partnership practice with a dispensary Owner in a partnership practice with out a dispensary The employer of other ODs Employed by another OD Employed by an MD Employed by a clinic or other facility Question Title * 4. Please fill in all boxes that apply for this location. Name of your partners Name of your employer Names of your employed ODs Staff size excluding doctors for this location Numbers of hours you work at this office per week If the office is adjacent to an optical, please name the business Question Title * 5. Do you have an additional practice location? Yes No Next