MEMBERSHIP APPLICATION FORM


(Revised w.e.f. 1 July, 2018)

REGD NO.: (S-171-92)

APPLICANT FULL NAME:
DATE OF BIRTH (dd/mm/yy):
 
PERMANENT ADDRESS:
STATE:
PIN CODE:
CORRESPONDENCE/ OFFICIAL ADDRESS:
STATE:
PIN CODE:
EMAIL ID:
MOBILE NUMBER:
ALTERNATE MOBILE NUMBER (if any):
QUALIFICATION (DIPLOMA/ DIGREE/ MASTER/ Ph.D):
COURSE/ DURATION
UNIVERSITY/ BOARD
YEAR OF PASSING
CURRENT OCCUPATION/ DESIGNATION:
TYPE OF MEMBERSHIP APPLIED FOR (Tick any one):
LIFETIME MEMBERSHIP
ASSOCIATE MEMBERSHIP
CORPORATE MEMBERSHIP
CORPORATE RENEWABLE
STUDENT MEMBERSHIP
INSTITUTE REGISTRATION
INSTITUTE RENEWABLE
 
ARE YOU A MEMBER OF ANY FOREIGN AND NATIONAL/ STATE OPTOMETRIC ORGANISATION:
YES
NO
IF SO, PLEASE SPECIFY.
DO YOU AGREE TO SERVE/ PROVIDE YOUR SERVICES TO IOA AS AND WHEN REQUIRED ? (Tick any one):
YES
NO
DO YOU AGREE TO ABIDE BY THE RULES/ REGULATIONS/ CODE OF ETHICS OF IOA AS PER CONSTITUTION ? (Tick any one):
YES
NO
DO YOU AGREE BY THE ORDERS/ INSTRUCTIONS/ GUIDELINES OF EXECUTIVE COMMITTEE/ BOARD OF IOA STRICTLY ? (Tick any one):
YES
NO
MENTION FULL ADDRESS TO WHICH THE CERTIFICATE/ ID TO BE COURIERED:
WOULD YOU LIKE YOUR CONTACT NUMBER TO VISIBLE TO IOA WEBSITE UNDER "FIND YOUR NEAREST OPTOMETRIST"?
YES
NO
ARE YOU A MEMBER OF ANY FOREIGN AND NATIONAL/ STATE OPTOMETRIC ORGANISATION:
YES
NO
  DECLARATION : INCASE OF MISCOUNDUCT / OR ANY ACTIVITY WHICH IS AGAINST THE RULES OF CONSTITUTION OF ASSOCIATION AND IS HARMFUL OR DAMAGING THE IMAGE OF ASSOCIATION PERFORMED BY THE UNDERSIGNED, IOA HOLDS THE AUTHORITY TO REVOKE/CANCEL / BLOCK MY MEMBERSHIP OR IMPOSE FINE

NOTE : Must be attach the following attachments also :-
  1. Witness Detail

  2. Notrized Sample Draft of Affidavit

  3. Payment Detail