MOSA Member

MOA Para Member

Member Application Form
Reason for Visit: *

New Para Membership Reinstated Para Membership Para Directory Update Transfer Membership
Sponsoring Doctor *

First Name Middle Name Last Name
Your Name *

First Name Middle Name Last Name
Maiden Name:
if applicable:
Date of Birth *

Month Day Year
Date
Gender *

Male Female Other Prefer not to respond
Certification
Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Email (MUST be exclusive to the individual):
example@example.com
Phone Number
Please enter a valid phone number.
Name of Practice
Practice Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Office Email:
example@example.com
Office Phone Number
Please enter a valid phone number.
Website Address (URL)
Payment Preference:

Bill Me@My Work Email Bill Me@My Home Email
Dues
Annual Paraoptometric dues as noted below regardless of time of year joined.

Note:You will be billed at a later date per the following Para Dues Rate program.
A. $40 for 1 Para/private pay or office paid
B. $80 per office location/2 Paras only
C. $100 per office location/3 or more Para
Preferred Email Address (Note: Emails must be exclusive to the individual for all correspondence, including dues invoices:
Preferred Mailing Address:
Comments/Additional Information
Please verify that you are human *
Should be Empty:

MOA Para Member