Form

Full Name: *
Maiden Name (if applicable)
Gender *	Male Female
Spouse
Practice Name
AOA ID Number (please enter "n/a" if you do not have one) *
Reason for application *	New Member Current Member Changing Classification Reinstated Member Transfer
If transferring, from which state
Main Office Address
Main Office Address 1
Main Office Address 2
Office City
Office State
Office ZIP
Office Phone
Office Fax
Office County
Home Address
Home Address 1
Home Address 2
Home City
Home State
Home ZIP
Home Phone
Home County
Preferred Mailing Address	Office Home
E-mail:
To protect our members’ privacy, FOA 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 FOA-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	Do not send me Member Bulletins via e-mail
FOA also hosts a member-to-member listserv, called the Communications Network. FOA does not generate messages to this list; rather messages are posted by local societies and FOA 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 Florida Optometry. Members must opt-in to this list.
Add my address to FOA’s Communications Network	Add my address to FOA’s Communications Network
Date of Birth *
Graduated from *
Optometric Graduation Year
Date of FL Licensure
FL License Number *
Year of Original License (if different than above)
State of Original License (if other than FL)
Legislators with whom you have a personal relationship
Have you previously been affiliated with FOA? *	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