OD Member Application & Directory Update Optometrist Membership and Dues Rates Optometrist Dues Billing/Payment Program Application Reason for Visit: SelectNew OD MembershipReinstated OD MembershipTransfer of MembershipChange of Dues ClassificationOD Member Directory Update If transfer, name previous state association: Notes: Change of dues classification for optometrists may be submitted only during the period from January 1 - April 30. Otherwise, changes will become effective as of January 1 of the following year. Please call the MOA central office with questions or to request "Retired" or "Life" membership at 573-635-6151 or email firstname.lastname@example.org. Personal Information First Name: MI: Last Name: Maiden Name (if applicable) Date of Birth: SelectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031 Select1950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013 Gender: MaleFemale Home Contact Information Address: City: State: SelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMDMEMAMIMNMSMOMTNENVNJNJNMNYNCNDOHOKORPARISCSCTNTXUTVTVAWAWVWIWY Zip: If Missouri, which county: SelectAdairAndrewAtchisonAudrainBarryBartonBatesBentonBollingerBooneBuchananButlerCaldwellCallawayCamdenCape GirardeauCarrollCarterCassCedarCharitonChristianClarkClayClintonColeCooperCrawfordDadeDallasDaviessDe KalbDentDouglasDunklinFranklinGasconadeGentryGreeneGrundyHarrisonHenryHickoryHoltHowardHowellIronJacksonJasperJeffersonJohnsonKnoxLacledeLafayetteLawrenceLewisLincolnLinnLivingstonMaconMadisonMariesMarionMcDonaldMercerMillerMississippiMoniteauMonroeMontgomeryMorganNew MadridNewtonNodawayOregonOsageOzarkPemiscotPerryPettisPhelpsPikePlattePolkPulaskiPutnamRallsRandolphRayReynoldsRipleySt. CharlesSt. ClairSte. GenevieveSt. FrancoisSt. LouisSt. Louis CitySalineSchuylerScotlandScottShannonShelbyStoddardStoneSullivanTaneyTexasVernonWarrenWashingtonWayneWebsterWorthWright Phone: Email (MUST be exclusive to the individual): Mobile: Note: Will publish only if no home number given. Primary Practice Information Practice Name: Web Site: Office Address: City: StateSelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMDMEMAMIMNMSMOMTNENVNJNJNMNYNCNDOHOKORPARISCSCTNTXUTVTVAWAWVWIWY Zip: Email (MUST be exclusive to the individual): Phone: Fax: Second Practice Information Name: Web Site: Address: City: State SelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMDMEMAMIMNMSMOMTNENVNJNJNMNYNCNDOHOKORPARISCSCTNTXUTVTVAWAWVWIWY Zip: Email (MUST be exclusive to the individual): Phone: Fax: Third Practice Locaton Name: Web Site: Address: City: State SelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMDMEMAMIMNMSMOMTNENVNJNJNMNYNCNDOHOKORPARISCSCTNTXUTVTVAWAWVWIWY Zip: Email (MUST be exclusive to the individual): Phone: Fax: Preferences May we email you? YesNo Preferred Email: : SelectHomeOffice Preferred Mailing: SelectHomeOffice Optometric Membership Information Note: Preferred Address and Payment Preference must match for location. Type of Membership: SelectOD MemberPartial Practice ODFaculty Associate ODFederal Services ODMissouri Non-Resident OD Partial Practice or Faculty Associate OD - Hours/Week: 012345678910111213141516 Payment Preference: SelectBill Me @ My Work AddressBill Me @ My Home Address Dues ScheduleSelectAnnualQuarterlyMonthly Annual dues amounts are prorated by the number of years since licensure up to 5 years, type of OD membership, and time of joining. Optometric Student Mentor:YesNo Referred to the MOA by: Current AOA #: List License Number(s): Date Original License Obtained (dd/mm/yy): State: SelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMDMEMAMIMNMSMOMTNENVNJNJNMNYNCNDOHOKORPARISCSCTNTXUTVTVAWAWVWIWY Have you ever been licensed in another state(s)? YesNo If yes, which state(s): Years Licensed: Is your license there still active?YesNo] Are you currently a member of another state's association? YesNo If yes, which state(s) / association(s). Will MOA be your primary state membership?YesNo Optometric Education School of Optometry Attended: Address: City: State SelectALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMDMEMAMIMNMSMOMTNENVNJNJNMNYNCNDOHOKORPARISCSCTNTXUTVTVAWAWVWIWY Zip Graduation Date (mm/dd/yy): Additional Residency: YesNo If Yes, where: Start Date Stop Date: [ Comments / Additional Information Please prove you're a human being -- type the characters shown here into the box below. After you hit the submit button below, you should see a green box with a message inside that says, "Thank you for joining / updating your information with the MOA!" If you don't see this message, please contact Sue@MoEyeCare.org Note:If you would like to pay your dues online, please click here.