MEMBERSHIP APPLICATION
"Join our family"
Member Type: Optometrist: Student:
Name: F: M: L:
Company:
Off. Address:
City, State, Zip C: S: Z:
Phones: O: F: R:
E-Mail:
Res. Address:
City, State, Zip C: S: Z:
Mail Preference: Office: Home:
Dues Preference: Annually: Quarterly: Monthly:
PROFESSIONAL
Education: Optometry School: Date of Graduation:
License: Date of Utah License: Other State License:
References: Ref 1: Ref 2:
PERSONAL Birth Date: Anniversary: Spouse Name:
Foreign Languages: 1: 2:
Membership Fees
Distribution AOA UOA TOTAL
Calendar year of origional license or transfer from post graduate membership 0 0 0
First year of UOA/AOA Membership $68.80 $49.33 $118.13
Second year of UOA/AOA Membership $137.60 $98.65 $236.25
Third year of UOA/AOA Membership $344.00 $246.64 $590.64
Fourth year of UOA/AOA Membership $516.00 $369.95 $885.95
Fifth year of UOA/AOA Membership $688.00 $493.27 $1181.27
UOA Student Membership $30.00