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>>>Membership Form
APPLICANT FULL NAME *
DATE OF BIRTH *
PERMANANT ADDRESS *
CITY*
PIN CODE *
STATE *
CORRESPONDENCE / OFFFICE ADDRESS*
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CITY *
PIN CODE*
STATE *
E-MAIL ID *
PASSWORD*
CONFIRM PASSWORD*
MOBILE NO *
ALTERNATE MOBILE NO (IF ANY )
QUALIFICATION
# COURSE / DURATION * UNIVERSITY / BOARD * YEAR OF PASSING*
1
2
3
4
5
6
CURRENT OCCUPATION / DESIGNATION *
TYPE OF MEMBERSHIP APPLIED FOR (Tick any one )*
LIFE MEMBERSHIP
ASSOCIATE MEMBERSHIP
CORPORATE REGISTRATION
CORPORATE RENEWABLE
STUDENT MEMBERSHIP
INSTITUTE REGISTRATION
INSTITUTE RENEWABLE
ARE YOU A MEMBER OF ANY FOREIGN OR NATIONAL/ STATE OPTOMETRIC ORGANIZATION *
Yes No
IF YES, PLEASE SPECIFY
DO YOU AGREE TO SERVE / PROVIDE YOUR SERVICVES TO IOA AS AND WHEN REQURIED ?(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 TO ABIDE BY THE ORDERS/INSTRUCTIONS/GUIDELINES OF EXECUTIVE COMMITTEE/BOARD OF IOA STRICTLY? (Tick any one )*
Yes No
WOULD YOU LIKE YOUR CONTACT NO. TO VISIBLE AT IOA WEBSITE UNDER "FIND YOUR NEARES OPTOMETRIST"?*
Yes No
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