Create a New Online Customer Account

New Customer Registration Form
After submitting this form you will receive an email containing your Username and Password. You will then be able to log in and shop our online store with discounted prices, free shipping, special offers, and other features.

First Name *
Last Name *
Company Name *

Shipping Address

Shipping Address *
City *
State *
Zip *

Billing Address if Different

Billing Address

Phone *
Email Address *
Company Type *
Tax Exempt # (required if tax exempt)
How did you hear about us *
Member ID (if applicable)
Send me a new catalog
Would you like a new catalog?

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A valid email address is required for order and shipping confirmations, and other online features.
Account setup information can also be emailed to, or fax this completed form to 816.237.2017.

Our store uses SSL Technology which protects your credit card information and insures your privacy.

All orders provide jobs and services to people with vision loss.
Thank you for your support of our mission.