OOA Application for Active Membership

Active Member

Any optometrist residing or practicing in the State of Ohio who holds a certificate of licensure from the Ohio State Board of Optometry, and who agrees to practice consistent with the Statement of Ethics of the Ohio Optometric Association, is qualified to apply for active membership and may become and active member of the Association. Active members may vote, hold office and are extended the privilege of debate. Your application will be reviewed and you will be contacted shortly.

Basic Information

First Name MI Last Name
Suffix Designations (O.D., Ph.D., etc.)
Maiden Name (if applicable)
Date of Birth ? Gender: Male Female
Preferred Email
Please send all correspondence to my: Home Office

Home Address

City State Zip
Home Phone Cell Phone

Practice/Business Name & Address

Employer Name
City State Zip
Office Phone Office Fax

Select Primary Practice Setting:

Self Employed:
Employed By:

Select Secondary Practice Setting:

Self Employed:
Employed By:

Select Other Practice Setting:

Self Employed:
Employed By:

Optometric Information

Optometry School
Graduation Date ?
Residency or Post-Graduate Program (if Applicable)
Year of Residency or Post-Graduate Program Completion
Ohio License Number Year Licensed
Out of State License Number(s)
Out of State License # Year Licensed
Out of State License # Year Licensed

The following section is voluntary.

Marital Status
Name of spouse (if applicable)
Military Service; Branch
Military Service; Status
Is there an OOA member who spoke with you about joining the association? If yes, please list the member OD who referred you to membership.
Name of Referring OD


I hereby apply for membership in the Ohio Optometric Association and the American Optometric Association. I understand fully and will adhere to, the schedule of dues payment and Association Bylaws and Code of Ethics.
Initials Date ?
   - denotes required fields