Membership Application

By submitting this application, I agree, if approved, to uphold the bylaws of the Utah Optometric Association and to support the officers and policies of this organization.

First Name: *

Middle Initial:

Last Name: *

Member Type: *

Optometrist

Student

2011 MEMBERSHIP FEES:

FULL MEMBER:

The balance of the year of origional licensure is $0.00.
YEAR FIRST SECOND THIRD FOURTH FIFTH
AOA $80.20 $160.40 $401.00 $601.50 $802.00
UOA $49.00 $98.00 $245.00 $367.50 $490.00
TOTALS $129.20 $258.40 $646.00 $969.00 $1,292.00

STUDENT MEMBERSHIP: $30.00 Annual

Email Address: *

Office Address:

Office City:

Office State:

Office Zip:

Office Phone:

Home Address:

Home City:

Home State:

Home Zip:

Home Phone:

Date of Birth: *

Spouse Name:

Optometry School: *

Grad Date: *

Lic Year: *

Year of origional license

Reference One:

Reference Two:

Send Mail To:: *

Utah Optometric Association

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Membership Application

"Serving Utah's Eyecare Needs Since 1951"

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UOA SPRING CONFERENCE

March 23 - 24, 2012

St. George, Utah

Click for Full Agenda

UOA

2012 Annual Convention

June 7-10, 2012

Zermatt Resort

Midway, Ut

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