Pennsylvania Optometric Association, American Optometric Association & Local Society
Please return completed application with dues payment to POA, 218 North Street, Harrisburg, PA17101. To obtain the amount of your dues (taking into consideration local society dues, AOA dues, year of licensure and time of year application is completed), contact the POA office at (717) 233-6455 or email . For additional information, please visit .
Gifts and dues payments to the POA, AOA and local societies are not deductible as charitable contributions for federal income tax purposes; however, they may be deductible as business expenses under other provisions of the Internal Revenue Code. Consult your tax advisor.
DateFull Name / Male / Female
Average Number of Hours Per Week (Eligibility Certification on page 2.)
Practice Name (If different thanFull Name)
Main Office Address / Home Address
County (Office) / County (Home)
Phone (Office) / Phone (Home)
Fax / Email
To protect our members’ privacy, the POA will not share, sell or distribute member email addresses beyond AOA and your local society.
MEMBER BULLETINS VIA EMAIL:In addition to individual association-to-member correspondence, we will periodically send you Member Bulletins containing legislative and regulatory alerts as well as information on eye care benefits, clinical care, quality management, pediatric programming, continuing education and other time-sensitive news. Member Bulletins are POA-to-member communications only; recipients cannot reply to or send messages. If you do not wish to receive Member Bulletins via email, please double-click to check here.
Preferred Mailing Address: / Office / Home
Date of Birth / Maiden Name (If applicable)
Optometric Graduate of / Year
Date of Pennsylvania License / License Number
Year of Original License (If different from above) / State of Original License
Legislators with whom you have a personal relationship
Spouse’s Name
Have you previously been affiliated withthe POA? / Yes / No
Have you previously been affiliated with the AOA? / Yes / No / If Yes, which state?
Mode of Practice: (Check all that apply.) / Areas of Specialized Practice: (Check all that apply.)
Solo Practice
Partnership
Group Practice
Corporate Affiliated / Employed by OD
Employed by Physician
Employed by Hospital
Other: / Geriatric
Pediatric
Contact Lens
Low Vision / Vision Therapy
Prosthesis
Industrial
Other:
POA OFFICE USE
Date Received / Legislative Districts (Home): / PA House / PA Senate / US House
Legislative Districts (Office): / PA House / PA Senate / US House
Comments:
ELIGIBILITY CRITERIA: Pennsylvania Optometric Association
POA BY-LAWS: ARTICLE II – Membership
Section 6. Partial Practice Membership
(a)Partial Practice membership is granted to those doctors of optometry who practice orlive in the Commonwealth of Pennsylvania and work three (3) days or less per week in compensated optometrically related activities and whose status for partial practice is certified annually by the member. For purposes of partial practice membership and its related dues, one day shall equal eight (8) hours.
(b)Partial Practice members in good standing shall be considered in accrediting any affiliated society's delegate votes in the House of Delegates.
(c)Partial Practice members shall pay dues in accordance with these by-laws.
(d)Partial Practice members shall have the privilege of the floor in the House of Delegates.
(e)Partial Practice members may hold elective office in this Association.
POA BY-LAWS: ARTICLE VII – Dues
Section 1. General Provisions
(b)The annual dues for Partial Practice members shall be fifty percent (50%) of the dues of Active members.
ELIGIBILITY CRITERIA: American Optometric Association
AOA BY-LAWS: ARTICLE I – Membership
Section 1. Classification and Qualifications; C. Affiliate Membership Classifications.
2. Partial Practice Members.
Partial Practice Members. An optometrist meeting the qualifications set forth in Article I, Section 1, Paragraph A who works sixteen hours or less per week in compensated, optometrically related activities shall be eligible for classification as a Partial Practice Member of this Association. A Partial Practice Member may affiliate through AFOS provided that the member meets the requirements under Article I, Section 1, Paragraph A.2(d).
AOA BY-LAWS: ARTICLE I – Membership
Section 2. Dues; C. Affiliate Membership Dues.
2. Partial Practice Members shall pay 60% of annual dues.
CERTIFICATION FOR PARTIAL PRACTICE MEMBERSHIP ELIGIBILITY
Please check any that apply.
q POA Partial Practice.I certify that I am eligible for Partial Practice Membership as outlined in POA By-Laws, Article II, Section 6(working three days/24 hours or less per week), and understand that I must recertify my eligibility annually.
q AOA Partial Practice.I certify that I am eligible for Partial Practice Membership as outlined in AOA By-Laws, Article I, Section 1, Paragraph C.2 (working 16 hours or less per week), and understand that I must recertify my eligibility annually.
Signature of Applying Member______
LOCAL SOCIETY CONFIRMATIONSignature of Society President or Secretary
Date / Please forward upon confirmation to the POA office.
POA/AOA Partial Practice ApplicationPage 2