MEMBERSHIP REQUEST/APPLICATION FORM

If you are interested in joining the association or if you are transferring from another state association, please complete the required information below. NYSOA will send you a packet of membership informational materials to your preferred mailing address upon receipt of your submission. Upon approval, NYSOA will contact you regarding dues information. If you have any questions, please feel free to contact the NYSOA office at (800) 342-9836.

* Denotes Required Field

First Name*
Middle Initial
Last Name*
Email*
Title
Date of Birth*		(Format: mm/dd/yyyy)
Sex*	Male Female
Home Address 1*
Home Address 2
Home City*
Home State*		Home Zip*
Home Phone*
Cell Phone*
Business Name
Business Address 1
Business Address 2
Business City
Business State
Business Zip
Business Phone
Fax
Referred by
Preferred Mailing Address*	Home Business
I am joining the Local Society in which I:	Live Work Other
Choose your Local Society:	Please choose: Cayuga Cortland Onondaga Oswego Albany Columbia Greene Montgomery Rensselaer Saratoga Schenectady Schoharie Warren Washington Dutchess Orange Sullivan Ulster Fulton Hamilton Herkimer Madison Oneida Nassau Clinton Essex Franklin Jefferson Lewis St. Lawrence Bronx Kings New York Queens Richmond Other Genesee Livingston Monroe Ontario Seneca Wayne Yates Broome Chenango Delaware Otsego Tioga Allegheny Cattaraugus Chautauqua Chemung Schuyler Steuben Tompkins Enrolled Students Suffolk SUNYCO Educators Erie Niagara Orleans Wyoming Putnam Rockland Westchester
License Number Students may leave this field blank
Year of Original Licensure Students may leave this field blank
Optometry School Attended*
Graduation Year*
Completed Residency?*	Yes No
If yes, year:
In which states are you licensed to practice? Students may leave this field blank
Are you a member of any other optometric societies?*	Yes No
If yes, please list:
Are you a faculty member at SUNYCO?*	Yes No
If yes, number of hours per week at SUNYCO:
Are you transferring from another state?*	Yes No
If yes, which state?:
Number of years in practice: Students may leave this field blank
Do you work 20 hours of week or less?*	Yes No
If yes, how many?
Is your spouse a current member?*	Yes No
If yes, spouse's name:
Has your certificate of registration ever been revoked, annulled, or suspended?*	Yes No
	If yes, please fax (518-432-5902) or email (NYSOA2020@AOL.COM) an explanation.
Are you interested in being listed for referrals for any of the following specialties?	Academy FAAO House Calls General Refractive Surgery Vision Therapy Contact Lenses Low Vision Sports Vision DPA Certified Employment services Medicaid Medicare TPA Certified TPA 2 Certified