Practice Name (required)

Practice Code (required)

Practice Address

Practice Postcode (required)

Your Name (required)

Your Email (required)

Additional Notes

Uncheck Box acts as Signature

Please complete the online form or download and use one form for each practice (clearly in block capitals), and return, signed and dated.

Post to

NIOS – PO Box 28, DROMORE, BT25 1YH

If you have any queries please contact NIOS General Secretary on 028 9269 8077 or by email to lizgillespie@optometryni.co.uk