FREE Subscription Form

							                                                                   FREE                       Subscription Form
                                                                                                           Business Information:
                                                                                                           Applications will not be processed if business information is not provided.

                                                                                                           Name______________________________________________________________
                                                                                                           Title________________________________________________________________
   A J O B S O N M E D I C A L I N F O R M AT I O N L L C P U B L I C AT I O N                             Company___________________________________________________________
              P. O. B OX 2 0 2 4 , S KO K I E , I L 6 0 0 7 6 - 7 9 2 4 U S A                              Address____________________________________________________________
                                                                                                           City____________________________________State_______Zip_____________
                                                                                                           Phone:_____________________________________________________________
                                                                                                           E-mail:_____________________________________________________________
                                                                                                           Your email address will be used to send renewal notices and information about optical news and updates

I would like to receive VM FREE of charge.                                                                 Fax:________________________________________________________________
❏ Yes        ❏ No                                                                                          By providing your fax number on this form, you are giving us consent to send you fax
                                                                                                           advertisements for Jobson Medical Information products and services at this number


                                                                                                           Personal Information:
Signature: (required)                                                                                      If you prefer to have your subscription sent to your home?
                                                                                                           If yes, please fill in below:
___________________________________________
                                                                                                           Address_____________________________________________________________
Date: (required)_______________________________                                                            City __________________________________ State ________ Zip ___________


                                                      All of the following questions must be answered to qualify.
1) Please check the ONE category that best describes your                6) Which best describes your business? (check only one)                 13) What is the square footage of your dispensary?
job function.                                                            Z ■ Optical Shop                        M ■ Conventional Chain          (check one)
10 ■ Optometrist                                                         B ■ Optometric Practice                 E ■ Department Store                 1 ■ Under 1,000         3 ■ 2,001-3,000
20 ■ Optician                                                            J ■ Optometric Group Practice           G ■ Drug Store                      2 ■ 1,000 - 2,000        4 ■ Over 3,000
30 ■ Ophthalmologist                                                     C ■ Ophthalmologic Practice/            F ■ Mass Merchandiser/                                       5 ■ No Dispensary
40 ■ Executive at Chain HQ                                                    Dispensary                             Warehouse Store
50 ■ Optical Product Buyer at Chain HQ                                   K ■ Multi-Discipline Practice                                           14) The number of full and part time employees at your
55 ■ Owner (not Optometrist or Optician)                                 N ■ Refractive Surgery/Laser Center                                     business are: (including owner/doctor/store manager)
60 ■ Lab Wholesaler/Distributor                                           I ■ OD Affiliated with Retail Location                                      1 ■ 1 to 2      3 ■ 5 to 10      5 ■ Over 20
61 ■ Lab/Distribution Executive                                          5 ■ HMO                                                                      2 ■ 3 to 4      4 ■ 11 to 20
65 ■ Retail Manager (not Optician)                                       4 ■ Optical Lab/Wholesale Distributor
70 ■ Regional Retail Manager (not Optician)                              6 ■ Other (Please specify)____________________________                  15) Which professionals are active at your business?
80 ■ Other (please specify)____________                                                                                                          (check all that apply)
                                                                         7) Are there multiple optical businesses at this address?                    10 ■ Optometrist(s)
2) Do you dispense? ■ Yes               ■ No                                (i.e., a separate O.D. practice.) ■ Yes      ■ No                         20 ■ Optician(s)
                                                                            If yes, name of other business________________________                    30 ■ Ophthalmologist(s)
3) Do you make or influence purchasing decisions?
     ■ Yes, (Specify all that apply below) ■ No                          8) Are refractions performed at your business?                          16) Retail Price Range of Majority of Eyeglasses sold
     1 ■ Frames                                                                ■ Yes     ■ No                                                    at your business. (check one)
     2 ■ Lenses                                                                                                                                       1 ■ Under $50            4 ■ $201-$300
     3 ■ Contact Lenses                                                  9) Does your business dispense?        ■ Yes ■ No                            2 ■ $51-$100             5 ■ Over $300
     4 ■ Equipment, Fixtures, Displays                                      If yes, specify below all that apply.                                     3 ■ $101-$200            6 ■ None sold
                                                                            1 ■ Rx glasses     2 ■ Sunglasses 3 ■ Contact Lenses
4) Is this a single location practice/dispensary, or is it                                                                                       17) The majority of frames dispensed at your business
part of a multi-location group of practices/dispensaries?                10) How would you describe the street location of your                  are (check one)
     A ■ Single Location                                                 business?                                                                    1 ■ Exclusive/designer lines
     B ■ Multiple Location                                                 1 ■ Freestanding Office/Store       4 ■ Strip Mall                         2 ■ Midrange lines
   If part of a multiple location group, how many                          2 ■ Office Building/Medical Complex 5 ■ Private Residence                  3 ■ Lower priced/managed care frames
practices/dispensaries in the total group?                                 3 ■ Enclosed Mall                                                          4 ■ None sold
     A■2        B■3         C ■ 4 or more locations in group
                                                                         11) Lens processing capabilities on-site at your business.              18) What is the approximate annual sales volume at your
5) Is your business a Franchise?       ■ Yes      ■ No                   (check all that apply)                                                  business?
                                                                              1 ■ Finishing (edging)          3 ■ Surfacing                           1 ■ Under $200,000
                                                                              2 ■ Casting                     4 ■ None                                2 ■ $200,001 - $300,000
                                                                                                                                                      3 ■ $300,001 - $500,000
                                                                         12) Number of frames/sunglasses on display at your                           4 ■ $500, 001 - $750,000
                                                                         business. (check one)                                                        5 ■ $750,001 - $1 Million
                                                                              1 ■ Under 300                  4 ■ 1,001-2,000                          6 ■ Over $1 Million
                                                                              2 ■ 301-500                    5 ■ 2,001-3,500
                                                                              3 ■ 501-1,000                  6 ■ Over 3,500                               PUBLISHER RESERvES tHE RIGHt tO REJECt ANY
OFC                                                                                                                                                                 NON-QUALIFIED REQUESt


    For faster service, please fax back to: (847) 763-9631 or subscribe on-line at www.submag.com/sub/vm