Affiliated Association
Prepared By
Date

2015 APPLICATION FOR POST GRADUATE MEMBERSHIP

AOA ID Number / Member Name
First / Middle Initial / Last
Suffix (Jr., Sr., etc.) / Designations (O.D., Ph.D., etc.) / Former/Maiden Names Used
CONTACT INFORMATION
Preferred Mailing Address Permanent Current
Permanent Address
Email
Telephone / Cell
Current/School Address
Email
Telephone
REQUIRED INFORMATION
It is the affiliate’s responsibility to obtain verification of the member’s residency status. The application cannot be processed with missing or incomplete verification information.
Name of school currently attending
School city, state
Degree(s) sought or program of study undertaken
Name of current residency internship or graduate program
Expected graduation date of post-graduate course or completion of residency or internship program
Name of Designated School, Residency, Faculty or State Board official.
Member Is
New
Reinstated
Transferred From
Effective Month of Membership
DEMOGRAPHIC INFORMATION
Date of Birth
Gender Male Female
Ethnicity White Caucasian
Black African American Hispanic
Native American Asian Other
Optometry School Attended
Year of Graduation
Licenses Obtained
Year / State
NPI Number
Military Service
Branch
Rank
Status / Active Reserve Retired
National Guard ROTC

2015 APPLICATION FOR POST-GRADUATE MEMBERSHIP

ANNUAL DUES OBLIGATION

Use the chart below to determine the 2015 annual dues obligation. No method of proration other than monthly as listed below is allowed.

Effective Month of Membership / 2015 Annual Dues / $
Effective Join Month
January / February / March / April / May / June / July / August / September / October / November / December
Post Graduate Member / $35.00 / $32.08 / $29.17 / $26.25 / $23.33 / $20.42 / $17.50 / $14.58 / $11.67 / $8.75 / $5.83 / $2.92
Affiliate Comments

Submit completed application to AOA Dues Accounting at . The approved application will be returned upon processing.

FOR AOA USE ONLY

AOA ID Number / 2015 Dues Obligation / $
Processed By / Date
AOA Comments