subject_line
Sight for All United in collaboration with Fitz Frames and Classic Optical
Protective eye wear or face shield orders
First Name
*
Last Name
*
Email
*
Cell Phone Number
*
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Do you wear prescriptive glasses or contacts for distance ?
*
Yes
No
Type of protective eye wear
*
Face Masks
Safety Eye Wear (Mahoning, Columbiana and Trumbull County Only)
Prescription Eye Wear
Non Prescription Eye Wear
Face shields
If Face Masks How Many?
Reason for protective eye wear
*
Front Line Medical Worker
Medical Worker
Essential Business
Other
Do You Have Access to an IPhone X or Higher
*
Yes
No
COVID-19 Risk of Exposure
*
Low
Medium
High
Company
*
Type of Business
Additional information
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