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PLEASE PRINT
NAME EXACTLY AS YOU WANT IT TO APPEAR ON MEMBERSHIP CERTIFICATE
Name ______________________________________________
Application Date _______________________
Address ___________________________________________
New _______________ Renewal ____________
City _______________________________
State ___________ Zip ___________ Direct Mail to: Home or Office
Phone (_____) ___________________
Fax (_____)________________ Date of Birth ______/_____/_______
Email ______________________________________
Website _______________________________________
Company name _____________________________________________________________________________
Address _______________________________________________
Length of Employment _________________
City ______________________________________________
State ________________ Zip ________________
Employed
by: Self______ MD _____ OD ______
Lab _____ Optician ______ Chain ______ Other
____________
Professional Certifications:
ABO#_________________________________ Expiration date_____________________________
JCAHPO#______________________________ Expiration date_____________________________
ABOM#________________________________ Expiration date_____________________________
STATE LICENSE#________________________ Expiration date_____________________________
NCLE# ________________________________ Expiration date_____________________________
Professional Affiliations: Circle all that apply
OAA
NAO PRO CLSA FHOAA Other ________________________
Education Level: High School _______ Associate _______ Bachelor’s
________ Other ____________
In submitting this application, I agree to abide by the bylaws of the
association and adhere to the
Code of Ethics. I also understand that the Board of Directors of the
Opticians Association of Illinois will
approve all applications.
Applicants Signature _______________________________________________________________
Membership Applied For:
REGULAR __________ $100 Any person ABO / NCLE certified and/or Optician
State License and/or has dispensed for at least three years.
ASSOCIATE _________ $50 Any person who does not qualify for regular
membership and has dispensed for less than three years.
PATRON ____________ $100 Any organization supporting the
Principals of the Association.
Sponsored by ____________________________________________________
Mail completed application to the above address. If you have any questions
call the 800 number above.
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