Pennsylvania Optometric Association, American Optometric Association & Local Society
Please return completed application with dues payment to POA, 218 North Street, Harrisburg, PA 17101. To obtain the amount of your dues (taking into consideration local society dues, AOA dues, year of licensure and time of year application is completed), contact the POA office at (717) 233-6455 or email . For additional information, please visit www.poaeyes.org.
Gifts and dues payments to the POA, AOA and local societies are not deductible as charitable contributions for federal income tax purposes; however, they may be deductible as business expenses under other provisions of the Internal Revenue Code. Consult your tax advisor.
DateMembership Category: Active Membership Associate Membership Federal Services Membership
Full Name / Male / Female
Practice Name (If different from above)
Main Office Address / Home Address
County (Office) / County (Home)
Phone (Office) / Phone (Home)
Fax / E-Mail
To protect our members’ privacy, POA will not share, sell or otherwise distribute member e-mail addresses.
MEMBER BULLETINS VIA EMAIL: 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 Member Bulletins via email, please check here.
LISTSERV: The POA also hosts a member-to-member listserv, called the Communications Network. The 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. If you do want to be added to POA’s listserv, please check here.
Preferred Mailing Address: / Office / Home
Date of Birth / Maiden Name (If applicable)
Optometric Graduate of / Year
Date of Pennsylvania License / License Number
Year of Original License (If different from above) / State of Original License
Legislators with whom you have a personal relationship
Spouse’s Name
Have you previously been affiliated with POA? / Yes / No
Have you previously been affiliated with AOA? / Yes / No / If Yes, which state?
Mode of Practice: (Check all that apply.) / Areas of Specialized Practice: (Check all that apply.)
Solo Practice
Partnership
Group Practice
Corporate Affiliation / Employed by OD
Employed by Physician
Employed by Hospital
Other: / Geriatric
Pediatric
Contact Lens
Low Vision / Vision Therapy
Prosthesis
Industrial
Other:
POA OFFICE USE
Date Received / Legislative Districts (Home): / PA House / PA Senate / US House
Legislative Districts (Office): / PA House / PA Senate / US House
Comments: