| |
Membership
> Membership Application
Yes,
I want to support optometry in Maryland!
Membership
investment in MOA is arranged on a sliding scale based upon number
of years in practice. If you are interested in joining MOA please
submit the application below and upon approval of your application
you will be notified of further information including the amount
of your membership investment.
To
register via mail or fax, complete and print out the registration
form below and either mail fax it to:
MOA
Headquarters
720 Light Street
Baltimore, MD 21230-3816
FAX: (410) 752-8295
|
Your Name:
|
|
Are you a:
New Member or
AOA Member Transferring From Another State
|
|
Home Street Address:
|
| City/State/Zip:
|
|
Home Phone:
|
| Business
Address:
|
| City/State/Zip:
|
| Business
Phone:
|
| Fax:
|
|
All mail to be sent to:
Home
Business |
| Email
Address:
|
|
Marital Status:
Single
Married
Maiden
Name
|
|
Name of Spouse:
|
|
Is Your Spouse a Member of the MOA?:
Yes
No
|
|
State and License Number:
|
|
Original State and Date of Licensure:
|
| Optometry
School Attended:
|
|
Month and Year of Graduation:
|
Did you complete a residency after graduation?:
Yes
No
If yes, where and during what year?:
|
| Date
of Birth:
|
In
what states are you currently licensed to practice?
|
Do you work part-time?
Yes
No |
If yes, how many hours a week do you work?
|
|
Has
your license ever been revoked, annulled, or suspended?
If so, give particulars:
|
|
Have you ever been brought up on charges before the state
Board of Examiners in Optometry or any other governmental
department, bureau, or official? If so,l give particulars:
|
Have
you ever been convicted of a crime? If so, give particulars:
|
|
Are
you interested in participating in our referral program?
(If so, please check areas of expertise)
|
(Please
note: This is not a secure site)
|
|
|
720
Light Street, Baltimore, MD 21230
TEL:
(410) 727-7800• FAX: (410) 752-8295
EMAIL:
MOA@assnhqtrs.com
|
|