Student Application

California Optometric Association offers complimentary membership to students and post-graduate students of optometry.

Applicant Information

First Name:
Last Name:
Middle Initial:

Preferred Mailing Address

Street Address:
City:
State, Zip: ,
Telephone:
Fax:
Email:

Home Address

Street Address:
City:
State, Zip: ,
Telephone:
Fax:
Email:

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:

Optometry Student

School of Optometry:
Year of Graduation:

Post-Graduate Student

Post-Graduate Student Membership requires certification of your full time status by an appropriate official of the post-graduate/residency program on that institution's letterhead.
Post Graduate Program Type:
Completion Date:
School of Optometry:
Year of Graduation:
CA License NO:
Date Licensed: