Student Membership Application

Pennsylvania Optometric Association and Pennsylvania Optometric Student Society (POSS)

If you have any questions, please contact the POA office at mail@poaeyes.org or call (717) 233-6455. Click here for additional information on POA Student Member Benefits.

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.

Full Name *
Maiden Name (if applicable)
Gender *	Male Female

College Address
Address 1 *
Address 2
City *
State *
Zip Code *
Phone


Home Address
Address 1
Address 2
City
State
Zip Code
Phone
County

Preferred Mailing Address *	College Home
Email Address *
To protect our members’ privacy, POA will not share, sell or otherwise distribute member e-mail addresses.

Date of Birth *
Which College of Optometry are you attending? *
Expected year of graduation *
Spouse's Name
State in which you plan to practice
Club or Organization Affiliations

Student Membership Application

College Address

Home Address