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Customer Application Form

Customer Application Form

Please complete each of the fields below. *Denotes mandatory fields.

Optical network

*Have you ever had an account with Alcon?
*MD/OD Requires state licensing; Hospital requires Pharmacy License
Do you require prescheduled delivery appointments?
Advanced notice requirement

Alcon products you are interested in

Formatted PO required?
Invoice/Statement delivery preference

*Form of business

*Have state tax exempt certificate?
*Would you like to pay via ACH/Direct Deposit?

Alcon requires that this information be provided for account consideration. Completion of this form, however, does not indicate that a request will be granted.


Customer acknowledges and agrees that the signing of this Customer Application Form shall constitute authorization under the Fair Credit & Reporting Act to Alcon and its Agents to utilize outside credit reporting agencies to provide reports on Customer in order to permit Alcon to appropriately evaluate the extension of any business credit. Alcon may also confirm trade and bank references. Customer agrees to release of information to other creditors and reporting agencies regarding Alcon’s credit experience with them. This authorization will remain valid and enforceable until Customer expressly revokes said authorization in writing to Alcon. Customer agrees to pay all charges according to the payment terms as designated on Alcon’s invoices.




Applicant agrees to pay according to terms and conditions stated herein. Creditor reserves the right to assess a monthly service charge on account paid outside of credit terms to the maximum amount permitted per jurisdiction. Creditor reserves the right to cease extension of credit without notice or to change terms of payment pursuant to any disclosure by customer according to section 409 of the Sarbanes Oxley Act. Applicant expressly agrees that it shall be liable and pay all attorneys’ fees, collection costs and court fees, and any other expenses, whether or not incurred in connection with litigation, including but not limited to attorneys’ fees and costs associated with the enforcement of any of the terms of this Application and attorneys’ fees and costs resulting from a default under this Application.


The above information is being provided in conjunction with a request of open credit terms from Creditor and its subsidiaries, divisions and affiliates (collectively “Creditor”). I hereby certify under penalty of perjury that the information provided is true to the best of my knowledge. The undersigned further understands that the Guaranty accompanying this Application is necessary to induce Creditor to extend credit to Applicant. If this Application is accepted by Creditor, the undersigned agrees to the terms and conditions attached to the Application and changed from time to time. The undersigned further agrees that all issues and disputes relating to any credit arrangement extended hereunder shall be governed in accordance with a competent jurisdiction chosen at the discretion of Creditor, without reference to conflicts of laws principles.


I (we) authorize Alcon Vision LLC to electronically debit my (our) account (and if necessary, electronically credit my (our) account to correct erroneous debits) to my (our) account (selected Account Type) at the financial institution (Bank) named above. Selecting the “Authorization Acknowledgement” below and submission of the form shall be deemed the electronic signature of the applicant.

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