OTGi Application Form
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1. Title *

 

2. Full Name *

*
*
 

3. Date of Birth *

   DD/MM/YYYY 
 
 

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

 

5. Sex *

 

6. Address *

 

7. Contact Number(s) *

*
 

8.  Email Address *

 

9. Occupation *

 

10. Full or Part time? *

 

11. When did you have your last eye examination? *

 

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

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Right Eye
Left Eye
 

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


 

Choose File
 

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