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Application For Opticians Association Of Georgia

                       (Please print this page and complete or you may also download an application in Adobe's PDF or Microsoft's Word, Doc, format by clicking the links below.)

OPTICIANS ASSOCIATION OF GEORGIA

APPLICATION FOR MEMBERSHIP

       January 1, 2011 Through December 31, 2011

Check one: ____ New Application ____Renewal

Check one:  I dispense:    ____ Contacts      ____ Eyeglasses     ____Both      ____ I do not dispense

PLEASE PRINT

Name___________________________________________ License # __________ Date_______________

Home Address__________________________________________________________________________

City ___________________________________State ____________________Zip code________________

E-mail ________________________________ Phone________________ Fax number________________

Company Name_________________________________________________________________________

Company Address_______________________________________________________________________

City _________________________________State_____________________Zip Code_________________

Education:   Degree________     Major_____________________     College_________________________

Certifications: ABO ____      NCLE ____      Refractometry ____     Other_____________________________

Training and Experience __________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Please include me on the OAG Email Member Alert Information List (OAG EMAIL) to receive urgent information regarding legislation and issues that directly affect the profession of Opticianry:  Yes____    No____

E-mail addresses will be used for OAG communication only: It will not be shared with other organizations or used for other purposes.

Dues

         ____Professional   ($125.00/one year)                                                 ___OAG Pins $ 8.00

         ____Professional   ($225.00/two year)                                                  ___G-BAG      $22.00

         ____Associate (Non-License - $50                                                       ___OAG Ball Caps $ 15.00

         ____New Licensed Optician (1st yr. n/c) _____Date Licensed                      ___Gray   ___Blue

         ____Student Optician (n/c)   ________________College                   ___ OAG Sweatshirt $ 30.00

         ____OAG Shirt $30.00    ____ Shirt size S/M/L/XL/XXL                   

                        __Burgundy ____ Gray  ___Blue

         ____ Add $5.00 Shipping and handling fee per item    

Total amount $______________ (Make checks payable to OAG)

Mail to: 

OAG
P.O. Box 830036
Stone Mountain, GA  30083
 

Credit – card #__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __   Expires __________

 ___ MasterCard         __ Visa            __ Discover Card              3 digits on back of Card _________

               Signature__________________________________________              

Phone:  Jeannie Ethridge/Secretary 770-503-1010           

 You can download an application in PDF format by clicking on the link below.  If you do not have a PDF reader on your computer, you can download a free one by clicking on the Adobe Reader logo below

The OAG Application in PDF Format, click here 

Here it is in Word or Doc format, click here

                          If you do not have Adobe Reader Click Here

                                      (you may want to unclick the toolbar that is offered on the download)