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Affiliated Association: / Date Submitted:
Prepared By:

This application is used to report a new or reinstated partial practice member, or a member transferring from another affiliate as a Partial Practice member during the 2013 membership year. A change in classification to partial practice membership must be submitted using the Notification of Change in Classification form during the open enrollment period of January 1-April 30, 2013. This application should not be submitted when a Change in Classification is being made. All information must be completed in full to process application. A copy of the approved application will be returned upon processing.

NAME AND CONTACT INFORMATION:

First / Middle Initial / Last / Suffix (Jr., Sr., etc.)
Designations (O.D., Ph.D., etc.) / Maiden Name (if applicable)
Home Address: / Practice /Business Name & Address:
Telephone:
Cell Phone: / Telephone:
Email Address:

Preferred Mailing Address: Home Business

DOB: / ______/ Gender: Male Female

Ethnicity: Caucasian / African Amer. / Asian / Hispanic / Native Amer / Other

Name of optometry school attended:
Year of graduation: / Year original license obtained:
List other states licensed in:
Select primary practice setting: / Select secondary practice setting:

Self Employed:

A.1 doctor- not affiliated with regional/national company

B.2-4 doctors - not affiliated with regional/national company

C.5+ doctors - not affiliated with regional/national company

D. Franchisee - 1 OD affiliated with regional/national company

E.Franchisee - Multiple ODs affiliated with regional/national company

F.Lessee – affiliated with regional/national company

U.Independent Contractor

G.Other Self-Employed

Employed By:

H.Optometrist(s) not affiliated with regional/national company

V.Optometrist(s) affiliated with regional/national company

I.Ophthalmologist(s)

J.HMO

K.Hospital/Clinic/Other Multidisciplinary

L.Regional/National Company

M.Armed Forces/VA/USPHS/ IHS

N.Educational Institution

O.Local/State/Federal Government

P.Optical/Ophthalmic Manufacturer or Wholesaler

W.Non-Optometry-Owned Independent Franchise/Optical

Q.Other Employed

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APPLICATION FOR

PARTIAL PRACTICE MEMBERSHIP

For the 2013 Membership Year

NEW, REINSTATED AND TRANSFERRING MEMBERS

New Member: / *Reinstated: / Transferred from:

* Members who have dropped and reinstated membership in the same calendar year with the same affiliate must pay full year dues.

CALCULATION OF DUES ASSESSMENT
Indicate the month the effective membership will begin by checking the appropriate box. No other method of proration other than monthly as listed below is allowed.
Join Date
Percentage of Full Dues / Jan 1 - Jan 15 / Jan 16 - Feb 15 / Feb 16 - March15 / Mar 16 - Apr 15 / Apr 16 - May 15 / May 16 - June 15 / June 16 - July 15 / July 16 - Aug 15 / Aug 16 - Sept 15 / Sept 16 - Oct 15 / Oct 16 - Nov 15 / Nov 16 - Dec 15 / Dec 16 - Dec 31
Works 16 hours or less per week / 60% / $518.40 / $475.20 / $432.00 / $388.80 / $345.60 / $302.40 / $259.20 / $216.00 / $172.80 / $129.60 / $86.40 / $43.20 / $0.00
Comments:
FOR AOA USE ONLY
AOA ID Number: / 2013 Dues Obligation: / $
Date Approved/By:
Comments:

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