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Partial Practice Membership Application

POA will invoice you for your dues. To obtain the amount of your dues (taking into consideration local society dues, AOA dues, POA dues, year of licensure and time of year application is completed), you may contact the POA office at mail@poaeyes.org or call (717) 233-6455. For additional information, please see dues and benefits area.

Gifts and dues payments to POA, AOA and local societies are not tax deductible as charitable contributions for tax purposes; however, they may be deductible as business expenses under other provisions of the Internal Revenue Code. Consult your tax advisor.

Fields with asterisks (*) are required.

Full Name: *
Maiden Name (if applicable)
Gender *	Male Female
Average Number of Hours Per Week
Practice Name
Spouse
Year applying for Partial Practice Membership
Are you currently a POA Member?	Yes No

Main Office Address
Address 1
Address 2
City
State
ZIP
Phone
Fax
County

Home Address
Address 1
Address 2
City
State
ZIP
Phone
County

Preferred Mailing Address	Office Home
E-mail:
To protect our members’ privacy, POA will not share, sell or otherwise distribute member e-mail addresses. In addition to individual association-to-member correspondence, we will periodically send you Member Bulletins containing legislative and regulatory alerts as well as information on eye care benefits, clinical care, quality management, pediatric programming, continuing education and other time-sensitive news. Member Bulletins are POA-to-member communications only; recipients cannot reply to or send messages. If you do not wish to receive these Member Bulletins via e-mail, please check the box below.
Do not send me Member Bulletins via e-mail
POA also hosts a member-to-member listserv, called the Communications Network. POA does not generate messages to this list; rather messages are posted by local societies and POA members and all recipients have the opportunity to reply to the entire list or a message’s sender. Typical postings include local society meeting information, clinical questions and discussions about issues related to Pennsylvania Optometry. Members must opt-in to this list.
Add my address to POA’s Communications Network

Date of Birth *
Graduated from *
Optometric Graduation Year
Date of PA Licensure *
PA License Number
Year of Original License (if different than above)
State of Original License (if other than PA)
Legislators with whom you have a personal relationship
Have you previously been affiliated with POA? *	Yes No
Have you previously been affiliated with AOA? *	Yes No
Mode of practice (check all that apply)	Solo Practice Partnership Group Practice Multidisciplinary Employed by OD Employed by Physician Employed by Hospital Employed by Other
Areas of Specialized Practice (check all that apply)	Geriatric Pediatric Contact Lens Low Vision Vision Therapy Prosthesis Industrial Other

Partial Practice Membership Application

Main Office Address

Home Address