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OPTICIANS ASSOCIATION OF GEORGIA

PAYPAL MEMBERSHIP/RENEWAL APPLICATION FOR 2018

Check one: ____ New Application ____Renewal  
***(renew by March 31st for discounted meeting registration rate)***

I dispense:    ____ Contacts      ____ Eyeglasses     ____Both      ____ N/A

PLEASE PRINT

Name___________________________________________ License/cert # __________

Preferred Name for Badge _________________________________________________

Address________________________________________________________________

City _________________________________State ________Zip code _____________

E-mail _______________________________________ Phone____________________

Please include me on the OAG EMAIL LIST 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.)

Employer Name_________________________________________________________

Education:   Degree________     Major______________    College_________________

Certifications: ABO ____      NCLE ____      Refractometry _____     Other___________

Additional Experience_____________________________________________________

Comments______________________________________________________________

Dues 

____Professional   ($125.00/ one year)     ____Professional   ($225.00/ two years)

____Professional   ($275.00/ three years)   ____Associate (Non-License $75)     

____ Professional Veteran/Senior Discount ($112.50/one year)***

____ Professional Veteran/Senior Discount ($180.50/two year)***

____ Professional Veteran/Senior Discount ($247.50/three year)***
                   (*** Verification may be required)

____New Licensed Optician (year of licensure is free)  Date Licensed _____                   

____Student Optician (n/c)           ___________________________College        

PRINT OUT THIS FORM TO FILL OUT, PRINT LEGIBLY, AND MAIL TO:
OAG  PO Box 868  Lithia Springs, GA  30122 
OR FAX TO: 770-528-0305
OR SCAN AND SEND TO: [email protected]
 

 Membership Year Is From January 1 until December 31 of the Current Year

You MUST renew your membership prior to January 31, 2018 to be eligible to register for events at the Current Member discounted price.

1 Year Membership: $125.00


2 Year Membership: $200.00



Voicemail -  (678) 658-2020    Fax – (770) 528-0305   Email - [email protected]

1 Year Membership: $125.00


THIS ---->https://oagonline.org/oag-membership/paypal-page.html