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Survey

Please complete all of the questions in this survey so we can process your order.  Make sure you use proper capitalization and punctuation.  If you have any questions about these questions, please do not hesitate to give us a call.
* Means this is a required field
 
   1.  What is your legal company name (exactly as registered with the IRS):
(This must match IRS records or the application will be rejected)

   2.  What is your Federal Business Identification Number (EIN/Tax ID):

   3.  What is your Business Category/Industry:
(If your company provides customized fitting services directly to patients, choose 621399-29)

   4.  What is the street address of your company as provided to the IRS:
(This must match IRS records or the application will be rejected)

   5.  What is the city of record for your IRS street address:

   6.  What is the state of record for your IRS street address:
(Use the 2 letter postal abbreviation)

   7.  What is the postal code (Zip code) of record for your IRS street address:

   8.  What type is your business entity?
   9.  What is your Company Website URL:

   10.  Authorized Contact Name:
(Provide details of an employee authorized to verify business information and represent your company during the verification process.)

   11.  Authorized Contact Job Title:

   12.  Authorized Contact Email Address:

   13.  Authorized Contact Cell Phone Number:

  Price Quantity
 Electronic Copy: $250.00 1