First Name *

BWC Pilot Program Administrator Name

Last Name *

BWC Pilot Program Administrator Name

Email *

Administrator Email

Phone *

Administrator Phone

Department/Agency Name *

End-User 1 - Name

End-User 1 - Rank

End-User 1 - Email

End-User 1 - Badge Number

End-User 2 - Name

End-User 2 - Rank

End-User 2 - Email

End-User 2 - Badge Number

End-User 3 - Name

End-User 3 - Rank

End-User 3 - Email

End-User 3 - Badge Number

LensLocker Portal Admin Email

LensLocker Portal Admin Cell Phone

Physical Mailing Address

Evaluation Period

15-Day Evaluation

30-Day Evaluation

BWC Model Selection

GEN 12.5 BWC

Eagle 13 BWC

BWC Pilot Program Terms & Conditions

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.