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
Remainder of calendar year of origional license or transfer from post graduate membership 0 0 0
First year of UOA/AOA Membership $76.80 $49.07 $125.87
Second year of UOA/AOA Membership $153.60 $98.13 $251.73
Third year of UOA/AOA Membership $384.00 $245.34 $629.34
Fourth year of UOA/AOA Membership $576.00 $368.00 $944.00
Fifth year of UOA/AOA Membership $768.00 $490.00 $1258.00
UOA Student Membership $30.00

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