Membership Application

I was referred to membership by

COA Member Name:
CA License No.

Applicant Information

First Name :
Last Name:
Middle Initial:
Designation:
(OD, FAAO, etc.)
Local Society:
Status: New Member Reinstate

Primary Work Location

Preferred Mailing Address Preferred Billing Address
Street Address:
City:
State, Zip: ,
Telephone:
Fax:
Email:
Company Name:
Company Website:

Home Address

Preferred Mailing Address Preferred Billing Address
Street Address:
City:
State, Zip: ,
Telephone:
Fax:
Email:

Mode of Practice

Self Employed:

Employed By:
Solo Group Optometrist
No. of OD's working here Ophthalmologist
Optical chain Franchise or Lessee HMO
Independent Contractor Hospital/Clinic/Other Multidisciplinary
Not Currently Active in Practicing Optometry: Optical Chain
Retired Unemployed Armed Forces/VA/USPHS/Government
Other (specify):
School/University
Industry
Do ophthalmologists practice at this location? Other (specify)
Yes No
   
I work 20 hours or less per week (total at all work locations.)
I work as a full-time Faculty Member at:

Professional Data

CA License Number:
Date Licensed: ,
License Type: Non DPA DPA TPA
If you hold a license of optometry in another state(s) indicate: State(s):
License Year(s):
School of Optometry:
Year of Graduation:
Did you attend a Post-Graduate/Residency Program? Yes No
Year Completed:

Demographics (optional)

Date of Birth: ,
Gender:
Marital Status:
Name of Spouse (if applicable)
If your spouse is an OPTOMETRIST, list his/her license No:
Ethnicity:
If other please specify:

Member Preferences

Find An Eye Doc is a free listing offered to COA member optometrists. It is an online locator service for the general public to use in searching for an optometrist in their area.
YES! Please include my practice/place of employment in this listing.
News Delivery: COA periodically sends email and fax blast communications to its members.
How would you prefer to receive COA Member News?
E-mail Fax Both email and fax
Online Membership Directory: Basic contact information will be included in a directory for COA members only.
I DO NOT WISH my contact information to be available in the online directory (only your name and society will be then be identified).

By submitting this application I hereby apply for membership in the California Optometric Association, the American Optometric Association and a local Optometric Society in my area. If elected, I will abide by their bylaws, Code of Ethics, and agree to pay all dues and assessments promptly.