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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.)

Now, Pay With PayPal and get your receipt by e-mail! Click HERE

If you are joining the OAG for the first time, we still need you to complete the following information.

Please complete the form and fax to 770-528-0305. You can print this page or click on the link at the bottom of the page, complete and fax. You may also send the information on the form in an e-mail to oaglist@att.net.

OPTICIANS ASSOCIATION OF GEORGIA

APPLICATION FOR MEMBERSHIP

January 1, 2012 to December 31, 2012

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)                                                

         ____Professional   ($225.00/two year)                                                 

         ____Associate (Non-License - $50)                                                     

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

         ____Student Optician (n/c)   ________________College                  

         Total amount $______________ (Make checks payable to OAG)    

Kat Clark – OAG Treasurer

OAG                                                            Fax – 770-528-0305

P.O. BOX 868                                             email – oaglist@att.net

Lithia Springs, GA  30122

Credit – card #__ __ __ __  -  __ __ __ __ - __ __ __ __ - __ __ __ __   expires _mm / yyyy_

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

 Signature__________________________________________              

 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)