Membership Application 

Please provide the following information:

Please provide the following information:

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail
URL

Send OAK Mail to Home or Work Address?

Home Work

Membership Type

Current Member (renewal) New Member

What Best Describes Your Work Type?

Dispense Eyeglasses  Dispense Contact Lenses
Optical Lab                Optometric Tech        
Ophthalmic Tech       Lab Tech 
Vendor                       Do Not Dispense        

What Certifications Do You Have?

ABO     NCLE    JCAHPO  Other 

Are You an Owner or Employee

Owner Employee

Print a copy of this form.

Mail the form (Contact Patti for the address) and your payment for $75.00 to:

e-mail:  Patti Ellis [patti.ellis88@gmail.com]

or

patti@ksopticians.org