Application Form

* Mandatory fields

SECTION I - NEW ACCOUNT INFORMATION

Please select a language first:*
Please select a country:*
Company / Account Name:*

Physical location

Physical Location (Street):*
Physical Location (City):*
Physical Location (ZIP/Postal Code):*
Physical Location State:*
Physical Location (Country/Territory):*

Is the invoice address different from the one above?*

Name of Entity to Invoice:*
Does a BVI account already exist for this entity:

Billing address

Billing Address (Street):*
Billing Address (City):*
Billing Address (ZIP/Postal Code):*
Billing Address State:*
Billing Address (Country/Territory):*
Public Customer Unique ID:*

Shipping address

Shipping Address 1 (Street):*
Shipping Address 1 (City):*
Shipping Address 1 (ZIP/Postal Code):*
Shipping Address 1 State:*
Shipping Address 1 (Country/Territory):*

Do you need to create another shipping address?*

Shipping address 2

Reason / Case to be used:*
Shipping Address 2 (Street):*
Shipping Address 2 (City):*
Shipping Address 2 (ZIP/Postal Code):*
Shipping Address 2 State:*
Shipping Address 2 (Country/Territory):*

Do you need to create another shipping address?*

Shipping address 3

Shipping Address 3 (Street):*
Shipping Address 3 (City):*
Shipping Address 3 (ZIP/Postal Code):*
Shipping Address 3 State:*
Shipping Address 3 (Country/Territory):*

SECTION II - CUSTOMER INFORMATION

Type of client: (tick one box per Zone)

Public or Private Institution:*
Type of customer:*

Other:*

Professional identification n° / Company registration number:*

Without a recognizable identification number we will not be able to create your account.

Professional identification

NPI Number:*
Medical Provider Number:*
Trade References:

Form to attach:

Tax / VAT Status:*

Please note that you will be charged tax if no relevant tax exemption proof is attached

VAT Number:* Tax exemption proof:* Download Tax exemption proof Form

Buying Group / Purchasing Group affiliation:*

Buying Group / Purchasing Group Name:*

GPO ID:*

Sort Code:*

Bank Account number:

Electronic Data Interchange (EDI)

Orders sent via EDI:*

GLN number for Address 1:*

GLN number for Address 2:*

GLN number for Address 3:*

Electronic Data Interchange (EDI)

Invoices received via EDI:*

GLN number for invoices:
Invoices received via:

Invoices received via Email:

Invoices received via Code Service:

SECTION III - CONTACT DETAILS

Main Contact First Name:*

Main Contact Last Name:*

Main Contact Phone Number:*

Main Contact Email Address:*

Order Contact Name:

Order Contact Phone Number:

Order Contact Email Address:

Invoice Contact Name:

Invoice Contact Phone Number:

Invoice Contact Email Address:

Finance Contact Name:

Finance Contact Phone Number:

Finance Contact Email Address:

SECTION IV - PARTNERSHIP WITH BVI

Products Interested in buying from us:

IOL Products:
Consumables Products:
Surgical fluids Products:
Equipment Products:
Other Products:

Have you have attached an order to your application?*

Please attach your order here:*

Shipment method:

FEDEX number:
UPS number:

Payment method:

Credit Card: Download Credit Card Authorization Form

SECTION V - OTHER INFORMATIONS

Please add any additional information you think we should know to set up your account:

By checking this box, I agree:*

That the information contained herein is accurate, complete, and true.
To pay all BVI invoices within BVI’s sales terms as stated on the invoice. Past due invoices will be subject to late fees.
That in the event of a billing discrepancy, you will pay the undisputed portion of all BVI invoices within terms of sale and submit a detailed description of the disputed amount.
To pay all costs of collection, including actual out-of-pocket expenses.
That BVI reserves the right, but not the obligation, to net monies due in order to offset outstanding debt due to BVI.
To inform BVI immediately by written notice of any change in ownership, address, or form of business.
The contents and information on this application have not been altered in any way.

Cookie	Duration	Description
_ga	2 years	The _ga cookie, installed by Google Analytics, calculates visitor, session and campaign data and also keeps track of site usage for the site's analytics report. The cookie stores information anonymously and assigns a randomly generated number to recognize unique visitors.
_gat_UA-142478797-1	1 minute	A variation of the _gat cookie set by Google Analytics and Google Tag Manager to allow website owners to track visitor behaviour and measure site performance. The pattern element in the name contains the unique identity number of the account or website it relates to.
_gcl_au	3 months	Provided by Google Tag Manager to experiment advertisement efficiency of websites using their services.
_gid	1 day	Installed by Google Analytics, _gid cookie stores information on how visitors use a website, while also creating an analytics report of the website's performance. Some of the data that are collected include the number of visitors, their source, and the pages they visit anonymously.
_hjAbsoluteSessionInProgress	30 minutes	Hotjar sets this cookie to detect the first pageview session of a user. This is a True/False flag set by the cookie.
_hjFirstSeen	30 minutes	Hotjar sets this cookie to identify a new user’s first session. It stores a true/false value, indicating whether it was the first time Hotjar saw this user.
_hjIncludedInPageviewSample	2 minutes	Hotjar sets this cookie to know whether a user is included in the data sampling defined by the site's pageview limit.
_hjTLDTest	session	To determine the most generic cookie path that has to be used instead of the page hostname, Hotjar sets the _hjTLDTest cookie to store different URL substring alternatives until it fails.
BrowserId	1 year	This cookie is used for registering a unique ID that identifies the type of browser. It helps in identifying the visitor device on their revisit.
CONSENT	2 years	YouTube sets this cookie via embedded youtube-videos and registers anonymous statistical data.
vuid	2 years	Vimeo installs this cookie to collect tracking information by setting a unique ID to embed videos to the website.

Cookie	Duration	Description
_fbp	3 months	This cookie is set by Facebook to display advertisements when either on Facebook or on a digital platform powered by Facebook advertising, after visiting the website.
fr	3 months	Facebook sets this cookie to show relevant advertisements to users by tracking user behaviour across the web, on sites that have Facebook pixel or Facebook social plugin.
VISITOR_INFO1_LIVE	5 months 27 days	A cookie set by YouTube to measure bandwidth that determines whether the user gets the new or old player interface.
YSC	session	YSC cookie is set by Youtube and is used to track the views of embedded videos on Youtube pages.
yt-remote-connected-devices	never	YouTube sets this cookie to store the video preferences of the user using embedded YouTube video.
yt-remote-device-id	never	YouTube sets this cookie to store the video preferences of the user using embedded YouTube video.

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Application Form

Home / Application Form

SECTION I - NEW ACCOUNT INFORMATION

SECTION II - CUSTOMER INFORMATION

SECTION III - CONTACT DETAILS

SECTION IV - PARTNERSHIP WITH BVI

SECTION V - OTHER INFORMATIONS