American Optometric Association (AOA) | Doctors of Optometry



137759027940002021APPLICATIONFORPOST GRADUATEMEMBERSHIP___________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: NEW, REINSTATED, AND TRANSFERRING POST GRADUATE MEMBERS.Current members requesting a change in classification to Post Graduate must be submitted using the Notification of Change form 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 New FORMCHECKBOX Reinstated FORMCHECKBOX Transferring from: 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 ?????VERIFICATION OF POST GRADUATE STATUSIt is the affiliate’s responsibility to obtain verification from the school or college of the member’s post graduate status. The application cannot be processed with missing or incomplete verification information. THIS INFORMATION IS REQUIRED TO PROCESS THIS APPLICATION.SCHOOL AFFILIATION: FORMTEXT ?????RESIDENCY SITE NAME: FORMTEXT ?????RESIDENCY CITY / STATE: FORMTEXT ?????RESIDENCY BEGIN DATE (MONTH/YEAR): FORMTEXT ?????RESIDENCY END DATE (MONTH/YEAR): FORMTEXT ?????CURRENT RESIDENCY, INTERNSHIP OR GRADUATE PROGRAM: FORMTEXT ????? FORMCHECKBOX Brain Injury FORMCHECKBOX Family Practice FORMCHECKBOX Low Vision Rehab FORMCHECKBOX Primary Eye Care FORMCHECKBOX Community Health FORMCHECKBOX Geriatric Optometry FORMCHECKBOX Ocular Disease FORMCHECKBOX Refractive Surgery FORMCHECKBOX Cornea & Contact FORMCHECKBOX Hospital Based Care FORMCHECKBOX Pediatric Optometry FORMCHECKBOX Vision Therapy & RehabANNUAL DUES OBLIGATIONDues schedule can be found at bottom of Application.No method of proration other than monthly as listed on the dues schedule is allowed. Members who have dropped and reinstated membership in the same calendar year with the same affiliate must pay full year dues.Effective Month of Membership FORMTEXT ?????Annual Dues:$ FORMTEXT ?????AOA OFFICE USE ONLYAOA ID Number: FORMTEXT ?????Processed by: FORMTEXT ?????Date: FORMTEXT ?????Dues Assessed:$ FORMTEXT ?????mm / dd / yyyyComments: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2021 ANNUAL DUES OBLIGATION SCHEDULEJANUARYFEBRUARYMARCHAPRILMAYJUNEPost Graduate Member$35.00$32.08$29.17$26.25$23.33$20.41JULYAUGUSTSEPTEMBEROCTOBERNOVEMBERDECEMBERPost Graduate Member$17.50$14.59$11.67$8.74$5.83$2.92 ................
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