Davis Vision Event/Materials/Giveaways Request Form

Client Manager Name *

Type of Request *

Client Event & Materials Request Client Event Only (No material shipments) Materials & Giveaways Materials Only Giveaways Only Eye Health Articles Only FEP

Type of Event *

Benefit Fair Health Fair (Vision Screenings) Presentations (Not applicable to Visionworks) HBO (Vision Screenings) HBO (No Vision Screenings) Conference/Events (Consecutive days & same location)

Type of Representation: Select one or all that apply. *

Client Manager Attending Only (Do not choose additional option) Client Manager Attending Too (Pick additional option) Davis Vision Associate Secured Representation (List in "Secured Representative" field) Visionworks Associate Enroller (If Visionworks not in area)

Date of Event *

Month Day Year

End Date of Event *

Month Day Year

Start & End Time *

: Hour Minutes AM/PM Option

until

until : Hour Minutes AM/PM Option

Client Name *

Group Code/Subgroup *

NOTE: Setup time is 1 hour prior to start time unless indicated differently in the notes field.

Event Location Address *

Address

Address 2

City State

Zip Code

Military Base? *

Yes No

Day of Event Contact Name *

Day of Event Contact Phone # *

Area Code Phone Number

Contact Email *

example@example.com

Expected Attendance *

Enter number of attendees

Type of Population *

Civilian Military Both

Branding *

Davis Vision Branded Visionworks Can Be Represented (giveaways, etc.)

Dress Code *

Business Casual Professional

Event Parking *

Free Pay to park Information not available (will provide soon)

Event Location *

Indoor Outdoor Information not available (will provide soon)

Secured Representative Name and additional information if needed. *

Note: If detailed information is not required submit NA.

Security Clearance *

Yes No

Event Location Detailed Information (directions, room number, etc.) *

Note: If detailed information is not required submit NA.

(check all that apply) *

License #/State License Plate # SSN Number Citizenship DOB Full Name Vehicle Make/Model/Year 2nd form of ID (i.e passport)

Bilingual or Preferred Language if Applicable

Bilingual, Spanish Speaker, etc.

REMINDER: If original event requests is urgent or requires revision please forward update via email to Rachel DeNoble, rachel.denoble@versanthealth.com and include original Jotform or Jotform ID number with updated information.

Date Materials Must Arrive By

Month Day Year

Do Not Ship Mateials Prior To

Month Day Year

Ship to Attention

Company Name

Shipping Address (if different than event location)

Address

Address 2

City State

Zip Code

Multiple Shipping Address Attachment

Upload a File

Plan Documentation *

OE Flyer Summary Brochure N/A or Will Provide Soon

Plan Documentation Attachments *

Upload a File

Attach OE Flyer and or Summary Brochure.

REMINDER: Attach "OE Flyer" and or "Summary Brochure" if applicable.

Plan Documentation Form #

Type in form # of OE Flyer or Benefit Summary Brochure

Plan Material Quantity *

# of copies of required

Plan Documentation Form # Multiplier and # of Forms Needed

Provider Directory State(s)

Provider Directory (qty)

Reminder: If the member or provider materials request is urgent or requires a revision to the request details (quanity, shipping address, etc...), email docrequest@versanthealth.com with the RT TICKET number you received via email from the original submission. (example is [davisvision.com #XXXXXX]

	Quantity
Lens Cloths
Pens
Female Sunglasses
Male Sunglasses
Goody Bags
Golf Tees
Golf Balls
Golf Towels
Golf Umbrellas
Lens Cleaner Bottles
Lens Cleaner Kits
Repair Kits
TABLECLOTHS (Plain White)
TABLE TOP DISPLAY: Get an Eye Exam Sign 8 1/2 x 11

Reminder: If original giveaways request is urgent or requires a revison email change to denise.gorgoni@davisvision.com.

Eye Health Articles *

Yes No

Eye Health Article(s)

	Quantity
"Aging Eyes"
"Healthy Vision"
"Eye Exam"
"Eye Strain"
"Glaucoma"
"Diabetes"

Additional Articles (List name - quantity)

Misc. Documents

Additional Attachments (i.e. Word Documents, etc)

Upload a File

Reminder: If the eye health articles request is urgent or requires a revision to the request details (quanity, shipping address, etc...), email docrequest@davisvision.com with the RT TICKET number you received via email from the original submission. (example is [davisvision.com #XXXXXX]

If there is a revision or change needed to the eye health articles themselves, contact Marketing.

Additional Client Manager Notes

1st Confirmation Email *

Add email address for recipient receiving confirmation

2nd Confirmation Email

Add email address for recipient receiving confirmation

NOTE: You will receive a "Thank You" email with confirmation of your submission. If you do not recieve this confirmation, please contact Rachel DeNoble, rachel.denoble@versanthealth.com

Event/Materials/Giveaways Request Form

Client Event Information

Shipping Information

Documentation Materials

Giveaways