FY26 State Society Membership Application

FY26 State Society Membership Application

Welcome to UOA! Please complete the required information and submit payment. Reach out to gcooper@opticians.org with any questions. Membership is valid through June 30, 2026
State Society Name*
Contact Name*

First NameLast Name
Contact Email*
example@example.com
What is your position in this State Society?*
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
State Society Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you interested in participating in UOA committees?*

YesNo
Select the committees you are interested in. (Checking the box does not guarantee membership on any committee). Committee formation is ongoing.

ConferenceEducationGovernment AffairsAdvocacy SubcommitteeLeadershipMarketingMembershipFinance
Officer Contact Information & Society Administrators
President*

First NameLast Name
President Email*
example@example.com
Vice President*

First NameLast Name
Vice President Email*
example@example.com
Secretary *

First NameLast Name
Secretary Email*
example@example.com
Treasurer *

First NameLast Name
Treasurer Email*
example@example.com
Who should be listed as the State Society Administrator(s)? Please list no more than two people.
Payment Method:

Credit CardCheck
State Society Membership

Please choose the membership category corresponding to the number of current members in your State. Payment is due at time of application. State Membership is valid through June 30, 2026
Membership Type

0-50 Member State Society Membership50-150 Member State Society Membership151+ Member State Society Membership
UOA Membership Fee
Mail check to:

United Opticians Assocation

PO BOX 910130

Lexington, KY 40591

Membership Option

0-50 Member State Society Membership

$400.00

51-150 Member State Society Membership

$1,000.00

151+ Member State Society Membership

$1,500.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

FY26 State Society Membership Application

Officer Contact Information & Society Administrators

State Society Membership