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OTGi Application Form
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1. Title
Required
- Required.
Ms
Miss
Mrs
Mr
Dr
*
2. Full Name
Required
- Required.
This question requires an answer
First Name
Surname
*
3. Date of Birth
Required
- Required.
*
*
4. Age
(You must be 18+ to register)
Required
- Required.
*
5. Sex
Required
- Required.
Male
Female
*
6. Address
Required
- Required.
*
7. Contact Number(s)
Required
- Required.
This question requires an answer
Main
Home
Alternative
*
8. Email Address
Required
- Required.
*
9. Occupation
Required
- Required.
*
10. Full or Part time?
Required
- Required.
<span style="color: rgba(0, 0, 128, 1)"><strong>Full time</strong></span>
<span style="color: rgba(0, 0, 128, 1)"><strong>Part time</strong></span>
*
11. When did you have your last eye examination?
Required
- Required.
Less than 6 months ago
1 year ago
2 years ago
<span style="color: #000080"><strong>2-5 years ago</strong></span>
<span style="color: #000080"><strong>More than 5 years ago</strong></span>
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
Sphere
Cyl
Axis
Near Add
Left Eye
Sphere
Cyl
Axis
Near Add
13. Please attach a photo of your spectacle prescription
(from your last opticians eye test, leave blank if not possible)
Drag and drop your files here
or click to browse your files
Maximum of 2 files, up to 50 MB each
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File: |FILE_INDEX| -
|FILE_NAME| -
|FILE_SIZE|
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14. Do your wear glasses or contact lenses at present?
Required
- Required.
No
Yes, glasses only
Yes, contact lenses and glasses
