American Optometric Association (AOA) | Doctors of Optometry



137759027940002021APPLICATIONFOR OPTOMETRICEDUCATOR___________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, OR TRANSFERRING OPTOMETRIC EDUCATORS.Current members requesting a change in classification to Optometric Educator 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 EDUCATOR STATUSTHIS INFORMATION IS REQUIRED TO PROCESS THIS APPLICATIONIt is the affiliate’s responsibility to obtain verification from the school or college of the member’s educator status. The application cannot be processed with missing or incomplete verification information.Is the member employed full-time by the school or college? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the member engage in the practice of optometry 16 hours or less per week? FORMCHECKBOX Yes FORMCHECKBOX NoIf the answers to both questions are yes, the member meets the qualifications for optometric educator membership.Member must be employed by school/college accredited by the Accreditation Council of Optometric Education. Please indicate school/college of current employment from the list below. If employed by school/college not shown in list, member is not eligible for this membership classification. FORMCHECKBOX Ferris State University Michigan College of Optometry, Big Rapids, MI FORMCHECKBOX Illinois College of Optometry, Chicago, IL FORMCHECKBOX Indiana University, School of Optometry, Bloomington, IN FORMCHECKBOX Inter American University of Puerto Rico, School of Optometry, Bayamon, PR FORMCHECKBOX MCPHS University School of Optometry, Worcester, MA FORMCHECKBOX Midwestern University Arizona College of Optometry, Glendale, AZ FORMCHECKBOX New England College of Optometry, Boston, MA FORMCHECKBOX Northeastern State University Oklahoma College of Optometry, Tahlequah, OK FORMCHECKBOX Nova Southeastern University, College of Optometry, Ft. Lauderdale, FL FORMCHECKBOX Pacific University, College of Optometry, Forest Grove, OR FORMCHECKBOX Pennsylvania College of Optometry at Salus University, Elkins Park, PA FORMCHECKBOX Southern California College of Optometry at Marshall B. Ketchum University, Fullerton, CA FORMCHECKBOX Southern College of Optometry, Memphis, TN FORMCHECKBOX State University of New York College of Optometry, New York, NY FORMCHECKBOX The Ohio State University, College of Optometry, Columbus, OH FORMCHECKBOX University of Alabama at Birmingham, School of Optometry, Birmingham, AL FORMCHECKBOX University of California, Berkeley, School of Optometry, Berkeley, CA FORMCHECKBOX University of Houston, College of Optometry, Houston, TX FORMCHECKBOX University of Missouri-St. Louis, College of Optometry, St. Louis, MO FORMCHECKBOX University of Montreal, Ecole d Optometrie, Montreal, QC, Canada FORMCHECKBOX University of the Incarnate Word Rosenberg School of Optometry, San Antonio, TX FORMCHECKBOX University of Waterloo, School of Optometry and Vison Science, Waterloo, ON, Canada FORMCHECKBOX Western University of Health Sciences College of Optometry, Pomona, CA FORMCHECKBOX Midwestern University Chicago College of Optometry, Downers Grove, IL FORMCHECKBOX University of Pikeville, Pikeville, KYPOSITION HELD: FORMCHECKBOX Assistant Professor FORMCHECKBOX Clinical Instructor FORMCHECKBOX Lecturer FORMCHECKBOX Associate Professor FORMCHECKBOX Professor FORMCHECKBOX Professor Emeritus FORMCHECKBOX Clinical Asst. Professor FORMCHECKBOX Dean FORMCHECKBOX Research Faculty FORMCHECKBOX Clinical Associate Professor FORMCHECKBOX Associate Dean (no teaching responsibilities)ANNUAL 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 SCHEDULEJANUARYFEBRUARYMARCHAPRILMAYJUNEOptometric Educator$486.00$445.50$405.00$364.50$324.00$283.50JULYAUGUSTSEPTEMBEROCTOBERNOVEMBERDECEMBEROptometric Educator$243.00$202.50$162.00$121.50$81.00$40.50 ................
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