Essilor Preferred Rewards (EPR) New Member Request Form

Please complete the form below with the required practice account information. The practice will be invited to enroll via email 1-3 business days pending the accuracy of the information provided. The enrollment invitation will be sent to the Practice Owner email provided on this form with a cc to any email(s) populated in the field, as well as to the email populated in the field. Note that the designated Practice Owner MUST complete the enrollment process by accepting program terms & conditions via the link in the enrollment email BEFORE they are eligible to earn points as an Essilor Preferred Rewards member. Per the T&Cs, members are eligible to earn points on the 1st day of the month following their enrollment. ALREADY HAVE A LOYALTY ID? Please go to https://rewards.essilorusa.com/enrollment/full to finalize your enrollment.

Submitter E-mail Address*

DBA*

Doing Business as Name

LEN*

Legal Entity Name associated with your EIN. Please reference your tax forms if uncertain.

EIN (Tax Identification #)*

EIN must be 9 digits / no hyphens please. Please reference tax forms if you are uncertain. NOTE: For practices with multiple locations operating under multiple EIN's, please submit each via this form separately

Primary Practice Address Line 1*

Primary Practice Address Suite

Primary Practice Address City*

Primary Practice Address State*

(State abbreviation only please)

Primary Practice Address Postal Code (Zip Code)*

Primary Practice Phone Number*

Format = 555-555-5555

Primary Owner Name*

Limited to 1 Owner (First and last name required)

Primary Owner Email Address*

Email address must not be associated with any existing EPR member. This is the email address that will receive all EPR program communications.

Invitation CC

Email address of additional practice staff member/person you would like to be included on the EPR invitation to ensure a quick enrollment

Additional Practice Location Address(s)

Please add the Address, Suite, City, State, Zip for EACH location that shares the same EIN. One primary location will be established per EIN. Points earned from other locations sharing the same EIN will roll up through primary location.

All Lab Name(s) and Lab Account Number(s)*

Note you MUST include name of lab AND associated lab account #'s for ALL EPR participating lab accounts associated with this practice for both primary address and any Additional Practice Locations listed. Missing detail will result in processing delays.

Essilor Account Executive/Lab Sales Representative

Email of Essilor Account Executive / Lab Sales Representative to be copied on invitation

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