PECAA | The Eye Care Industry’s Premier Alliance & Buying Group

HEA Advantage Membership Agreement

Welcome to HEA Advantage! Step One in getting your membership in place is to provide the information requested in the form below. Upon submitting, a DocuSign envelope will be generated and emailed to the Principal Owner and any additional Owner at the email address provided in the application. Each Owner should check their email inbox to complete the HEA Advantage Membership Agreement process via DocuSign. If you have any questions regarding this process, please reach out to your HEA Solutions Specialist before completing the form.

* Required

HEA Advantage I elect to have my vendors billed through consolidated billing

Please provide an Option.

* Practice Name

Please provide a Practice Name.

* Business Type

Please provide a Business Type.

DBA

* Practice Email

Please provide a Practice Email with a valid regex format of [email protected].

* Title

Please provide a Title.

PECAA Max Member ID

* Billing Address

Please provide a Billing Address.

* City

Please provide a City.

* State

Please provide a valid State.

* ZIP

Please provide a ZIP.

* Shipping Address

Please provide a Shipping Address.

* City

Please provide a City.

* State

Please provide a State.

* ZIP

Please provide a ZIP.

* Practice Phone Number

Please provide a Practice Phone Number.

Practice Fax Number

* Federal Tax ID

Please provide a Federal Tax ID.

# Principal Owner(s)

Additional Billing Addresses

Additional Shipping Addresses

* Principal Owner Last Name

Please provide a Principal Owner Last Name.

* Principal Owner First Name

Please provide a Principal Owner First Name.

* Email Address

Please provide an Email Address.

* Phone Number

Please provide a Phone Number.

* Owner(s) Home Address

Please provide an Owner(s) Home Address.

* City

Please provide a City.

* State

Please provide a State.

* ZIP

Please provide a ZIP.