Join KOA - Kentucky Optometric Association

Name*

First Middle Initial Last Suffix

Main Office Name

Office Address

Street Address City State ZIP Code

Office Phone

Office Fax

Office Website

Do you have a branch office?

Yes
No

Branch Name

(if Applicable)

Branch Office

Street Address City State ZIP Code

Branch Phone

Home Address*

Street Address City State ZIP Code

Email Address*

Cell Number*

Date of Birth*

Optometry School*

Year Graduated*

Preferred Mailing Address?*

Home
Office

AOA Member transferring from another state?

Yes
No

If Yes, Which State?

Currently a Resident?

Yes
No

Currently an Optometry Student?

Yes
No

Consent*

I agree.

In submitting this application, I hereby agree to comply with the terms and requirements of the Association, as set forth in the KOA Articles of Incorporation, Constitution and Bylaws. I understand that this application must be approved by the Board of Trustees of the KOA.

Name

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Membership Application

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