American Optometric Association, Attn: Dues Accounting
243 North Lindbergh Blvd., Floor 1, St. Louis, MO 63141-7881
(800) 365-2219
Fax: (314) 983-7301
Email: DuesAccounting@aoa.org
Web site: www.aoa.org
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Affiliated Association:
APPLICATION FOR
PARTI AL PRACTICE
MEMBERSHIP
For the 2013 Membership Year
Date Submitted:
Prepared By:
This application is used to report a new or reinstated partial practice member, or a member transferring from another affiliate
as a Partial Practice member during the 2013 membership year. A change in classification to partial practice membership must be
submitted using the Notification of Change in Classification form during the open enrollment period of January 1-April 30, 2013. This
application should not be submitted when a Change in Classification is being made. All information must be completed in full to
process application. A copy of the approved application will be returned upon processing.
NAME AND CONTACT INFORMATION:
First
Middle Initial
Maiden Name (if applicable)
Home Address:
Practice /Business Name & Address:
Telephone:
Preferred Mailing Address:
Ethnicity:
Suffix (Jr., Sr., etc.)
Designations (O.D., Ph.D., etc.)
Telephone:
Cell Phone:
Email Address:
DOB:
Last
Home
Business
________________________________________
Caucasian /
African Amer. /
Asian /
Gender:
Hispanic /
Native Amer /
Name of optometry school attended:
Year of graduation:
List other states licensed in:
Female
Other
Year original license obtained:
Select primary practice setting:
Self Employed:
A. 1 doctor- not affiliated with
regional/national company
B. 2-4 doctors - not affiliated with
regional/national company
C. 5+ doctors - not affiliated with
regional/national company
D. Franchisee - 1 OD affiliated with
regional/national company
E. Franchisee - Multiple ODs affiliated
with regional/national company
Male
Select secondary practice setting:
F.
U.
G.
Lessee – affiliated with
regional/national company
Independent Contractor
Other Self-Employed
Employed By:
H. Optometrist(s) not affiliated with
regional/national company
V. Optometrist(s) affiliated with
regional/national company
I.
Ophthalmologist(s)
Page 1 of 2
J. HMO
K. Hospital/Clinic/Other
Multidisciplinary
L. Regional/National Company
M. Armed Forces/VA/USPHS/ IHS
N. Educational Institution
O. Local/State/Federal Government
P. Optical/Ophthalmic Manufacturer or
Wholesaler
W. Non-Optometry-Owned Independent
Franchise/Optical
Q. Other Employed
APPLICATION FOR
PARTIAL PRACTICE MEMBERSHIP
For the 2013 Membership Year
NEW, REINSTATED AND TRANSFERRING MEMBERS
New Member:
*Reinstated:
Transferred from:
* Members who have dropped and reinstated membership in the same calendar year with the same affiliate must pay full year dues.
CALCULATION OF DUES ASSESSMENT
Indicate the month the effective membership will begin by checking the appropriate box. No other method of proration other than monthly as listed below is allowed.
Join Date
Works 16 hours or less per week
Percentage
of Full Dues
Jan 1 Jan 15
Jan 16 Feb 15
Feb 16 March15
Mar 16 Apr 15
Apr 16 May 15
May 16 - June 16 - July 16 June 15
July 15
Aug 15
Aug 16 Sept 15
Sept 16 Oct 15
Oct 16 Nov 15
Nov 16 Dec 15
Dec 16 Dec 31
60%
$518.40
$475.20
$432.00
$388.80
$345.60
$302.40
$172.80
$129.60
$86.40
$43.20
$0.00
$259.20
$216.00
Comments:
FOR AOA USE ONLY
AOA ID Number:
2013 Dues Obligation:
$
Date Approved/By:
Comments:
Page 2 of 2
Revised Jan 2013