OTGi Application Form

OTGi Application Form

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2. Full Name
*

First Name	*
Surname	*

3. Date of Birth
*

	DD/MM/YYYY

4. Age (You must be 18+ to register) *

5. Sex
*

Male
Female

6. Address
*

7. Contact Number(s)
*

Main	*
Home
Alternative

8. Email Address
*

9. Occupation
*

12. What is your spectacle prescription? (from your last opticians eye test, leave blank if unsure) NOTE: If using a smart phone, turn screen landscape

	Sphere	Cyl	Axis	Near Add
Right Eye	Right Eye Sphere	Right Eye Cyl	Right Eye Axis	Right Eye Near Add
Left Eye	Left Eye Sphere	Left Eye Cyl	Left Eye Axis	Left Eye Near Add

13. Please attach a photo of your spectacle prescription (from your last opticians eye test, leave blank if not possible)

File: {{filename}}delete

Choose File

14. Do your wear glasses or contact lenses at present? *

No
Yes, glasses only
Yes, contact lenses and glasses