Last Name First Name * PRIMARY OFFICE Street Address * Mailing Address City * State * Zip * Phone Fax SECONDARY OFFICE Street Address Mailing Address City State Zip Phone Additional Office Locations RESIDENCE ADDRESS Street Address Mailing Address City State Zip Phone Mail Preference * Primary Practice Secondary Practice Home Other Other Address Preferred Email * MEMBERSHIP INFORMATION Are you currently a member of organized optometry? AOA Student Member Member of Another State AFOS Member Other Not a Member PROFESSIONAL DATA Year of Graduation School of Optometry Did you complete a residency? * Yes No Year of initial licensure PRACTICE SETTING Check all that apply: * Practicing Full Time (20 hrs+/week) Practicing Part-time (up to 20 hrs/week) Resident Federal Service Member Retired Unemployed Other Do you accept: Medicare Medicaid POLITICAL INFORMATION Party Affiliation Democrat Republican Independant Non-Partisan Unknown Rather not say List any political contacts PERSONAL INFORMATION Gender * Male Female Date of Birth Marital Status Single Married Name of Spouce (if applicable) Children's Names & Ages I hereby apply for active membership in the Alaska Optometric Association. If granted membership into the Association, I will abide by its bylaws, and the AKOA Code of Ethics, and agree to pay all dues and assessments promptly. I agree to keep in confidence professional and confidential information as may be supplied by the Association. Signature