Priority Application

New Practiitioner Priority Membership & Information Update Card This application is for students specifically in their fourth year of optometry school, who want to have their California Optometric Association membership activated as soon as they are licensed in California. If you're not ready to commit, options are available to update your address only, so we can stay in touch with you.

Membership Application

Activate Priority Membership
Address Update Only
I do not plan on practicing optometry in california
I will be entering a post-graduate residency program. Please make me a COA post-graduate student member.

Applicant Information

First Name :
Last Name:
Middle Initial:

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:

Professional Data

School of Optometry:
Year of Graduation:
If attending post-graduate/residency program please indicate:
Institution:
PENDING:  
CA License Number:
Date Licensed: mm/dd/yyyy
License Type: Non DPA DPA TPA
If you hold a license of optometry in another state(s) indicate: State(s):
License Year(s):

Demographics (optional)

Date of Birth: mm/dd/yyyy
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

As a PRIORITY COA MEMBER, you will receive member communications and will also be listed in COA’s online member directory.
News Delivery: for e-newsletter and fax blast communications 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).
DO NOT include my practice/place of employment in this listing once my membership is activated.

Eligibility in the California Optometric Association requires an optometrist to hold a current, unrestricted license to practice optometry under the laws of the State of California. Your membership application for PRIORITY MEMBERSHIP is an agreement that COA will automatically process your membership fully with AOA, COA, and the local society as soon as we are notified of your California licensure. The ascending dues scale will go into effect as soon as the application is active.

By submiting this form I hereby apply for membership in the California Optometric Association as a PRIORITY MEMBER and agree to the automatic processing of my membership once licensed as a California optometrist. If elected, I will abide by the bylaws and Code of Ethics of the American Optometric Association, the California Optometric Association, and the local optometric society, and I agree to pay all dues and assessments promptly.