Student Applications | California Optometric Association

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

First: *

Last Name: *

Middle Initial:

Preferred Mailing Address

Street Address: *

City: *

State: *

Zip Code: *

Telephone: *

School Email: *

Personal Email: *

I DO NOT WISH my contact information to be available in the online directory (only your name and society will then be identified).

Street Address: *

City: *

State: *

Zip Code: *

Telephone: *

Date of Birth (mm/dd/yy): *

Gender: *

Marital Status:

Name of Spouse (if applicable):

If your spouse is an OPTOMETRIST, list his/her license #:

Ethnicity:

School of Optometry: *

Year of Graduation: *

Post-Graduate Student Membership requires certification of your full-time status by an appropriate offical of the post-graduate/residency program.

Post Graduate Program Type:

Post Graduate Program Location

CA License #:

Completion Date:

New graduates are exempt from dues for the balance of the year in which you graduate or complete your residency.

Post-Graduates/Residents are assessed $35 annual dues for AOA membership/COA dues are waived.

Your form submission WILL be encrypted using SSL to ensure your privacy.