Eye Bank Registration

"*" indicates required fields

Thank you for your interest in becoming an Eye Bank Supplier with Lions World Vision Institute.
Please complete the following information and a member of our team will reach out as soon as possible.

Eye Bank

* indicates required

Name:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:*

Fax:

Executive Director

Name:*

Email:*

Phone:*

Quality Assurance

Contact Name:*

Email:*

Phone:*

Fax:

Distribution

Contact Name:*

Email:*

Phone:*

Accounting

Contact:*

Email:*

Phone:*

Fax:

EBAA Accreditation

Expiration:*

Certificate Upload:*

Accepted file types: pdf, png, jpg, Max. file size: 5 MB.

FDA License

Expiration:*

License Upload:*

Accepted file types: pdf, png, jpg, Max. file size: 5 MB.

Other License

Other License Upload:

Accepted file types: pdf, png, jpg, Max. file size: 5 MB.

example: New York, Maryland, Canada, etc

Main Internal Tissue Identification Type

ISBT (FEIN, DIN, product code)*

Yes

Unique Eye Bank Identification*

Yes

Fees

Please list fees for the following:

Penetrating Keratoplasty (PKP):

Descemet’s Stripping Automated Keratoplasty (DSAEK):

Descemet’s Stripping Automated Keratoplasty Preload (DSAEK Preload):

Descemet’s Membrane Endothelial Keratoplasty (DMEK):

Descemet’s Membrane Endothelial Keratoplasty Preload (DMEK preload):

Courier Fees

FedEx:

UPS:

Expedited Courier:

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Save the Date

Eye Bank

Executive Director

Quality Assurance

Distribution

Accounting

EBAA Accreditation

FDA License

Other License

Main Internal Tissue Identification Type

Fees

Courier Fees