Life Membership Application

Full Name *
Practice Name

Main Office
Address
City
State
Zip Code
Phone
Fax
County

Home Address
Address
City
State
Zip Code
Phone
County

Preferred Mailing Address	Office Home
Date of Birth *
PA License Number
Optometric Practice Status *	Full Time Part Time Retired
Retirement Date
Currently receiving Social Security? *	Yes No
Date Social Security Benefits Began
If application is due to permanent incapacity, please briefly describe the nature of the condition.
Email Address *

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

Life Membership Application

Main Office

Home Address