American Optometric Association (AOA) | Doctors of Optometry



123467427940002021APPLICATIONFORLIFEMEMBERSHIP__________________RETURN COMPLETED APPLICATION BY MAIL OR EMAIL TO:American OptometricAssociationATTN: Dues Accounting243 N. Lindbergh Blvd, Floor 1St. Louis, MO 63141Phone: 800.365.2219Email: DuesAccounting@___________________PLEASE NOTE:This application is for:Reinstated Life Members;Transferring Life Members;Members Requesting a Change in Classification to LifeAll requests must be submitted during the open enrollment period of January 1 through April 30*. The approved form will be returned upon processing.*If the April 30 deadline falls on a weekend, the deadline is extended to the first Monday following the deadline.AFFILIATE OFFICE USE ONLYAffiliate Association: FORMTEXT ?????Prepared By: FORMTEXT ?????Date: FORMTEXT ?????mm/dd/yyyyComments: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MEMBERSHIP INFORMATIONMember is: FORMCHECKBOX Currently life and is FORMCHECKBOX Transferring from: FORMTEXT ?????or FORMCHECKBOX Reinstated FORMCHECKBOX Changing classification to life and meets years of membership requirement FORMCHECKBOX Changing classification to life and does NOT meet years of membership requirement. Life membership exceptions must be completed.Effective Month of Membership: FORMTEXT ?????AOA ID Number: FORMTEXT ?????First Name: FORMTEXT ?????Middle Initial: FORMTEXT ?????Last Name: FORMTEXT ?????Suffix (Jr., Sr., etc.): FORMTEXT ?????Designations (OD, PhD, etc.): FORMTEXT ?????Former / Maiden Name: FORMTEXT ?????CONTACT & DEMOGRAPHIC INFORMATIONPreferred Mailing Address: FORMCHECKBOX Home FORMCHECKBOX BusinessHome Address: FORMTEXT ????? FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Phone:( FORMTEXT ?????) FORMTEXT ?????- FORMTEXT ?????Cell:( FORMTEXT ?????) FORMTEXT ?????- FORMTEXT ?????Email: FORMTEXT ?????Business / Practice Name: FORMTEXT ?????Business Address: FORMTEXT ????? FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Phone:( FORMTEXT ?????) FORMTEXT ?????- FORMTEXT ?????Email: FORMTEXT ?????Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Choose Not to DiscloseDate of Birth: FORMTEXT ?????Marital Status: FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Widowedmm / dd / yyyy FORMCHECKBOX Partner FORMCHECKBOX Unknown FORMCHECKBOX Choose Not to DiscloseName of Spouse: FORMTEXT ?????Ethnicity / Race:Hispanic / Latino origin? FORMCHECKBOX Yes FORMCHECKBOX Noand / or FORMCHECKBOX White FORMCHECKBOX Black / African-American FORMCHECKBOX Asian FORMCHECKBOX Native American FORMCHECKBOX Alaska Native / Pacific Islander FORMCHECKBOX Other FORMTEXT ?????NPI Number: FORMTEXT ?????Military Service:Branch: FORMCHECKBOX Army FORMCHECKBOX Marine Corps FORMCHECKBOX Navy FORMCHECKBOX Air Force FORMCHECKBOX Coast Guard FORMCHECKBOX National GuardStatus: FORMCHECKBOX Active FORMCHECKBOX Inactive FORMCHECKBOX Reserves FORMCHECKBOX RetiredOptometry School Attended: FORMTEXT ?????Year of Graduation: FORMTEXT ?????Licenses Obtained:State: FORMTEXT ?????Year: FORMTEXT ?????State: FORMTEXT ?????Year: FORMTEXT ?????LIFE MEMBERSHIP EXCEPTIONSThis section is to be filled out ONLY if member does not meet AOA years of membership requirement. Exceptions to this requirement can be made for the following reasons: terminal illness; serious debilitative disease; when the member has been deemed a life member of the affiliated association and does not meet the years of membership requirement. These exceptions for Life membership are subject to the approval of the AOA Secretary Treasurer.Is the nominee terminally ill or do they suffer from a serious debilitative illness? FORMCHECKBOX Yes FORMCHECKBOX NoIf the answer to the above question is YES, then the member meets the qualifications, and you may proceed with the application. If the answer is NO, please see the question below.Is the nominee a life member in the affiliated association? FORMCHECKBOX Yes FORMCHECKBOX NoIf the answer to the above question is NO, then the member does not meet the qualifications of life membership. If the answer is YES, the rational or circumstance for requesting life membership must be given for consideration by the AOA Secretary-Treasurer. Please provide an explanation of the request in the space below; attach additional sheets as needed. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????AOA OFFICE USE ONLYAOA ID Number: FORMTEXT ?????Processed by: FORMTEXT ?????Date: FORMTEXT ?????Dues Assessed:$ FORMTEXT ?????mm / dd / yyyyComments: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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