Optometry Australia

1) Personal Details 2) Contact Details 3) Other Details 4) Review & Declaration 5) Payment

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Membership Application Form

In which state is your primary practice located.

Membership Category

Personal Details

Please use title case, e.g. (John Smith)

Title

First Name *

Middle Name

Surname *

Other Name/Preferred Name (for all correspondences) *

Gender *

Please describe your gender

Date of Birth *

Preferred Email *

Re-enter Preferred Email *

Have you been a member with us previously?

Are you of Aboriginal or Torres Strait Islander origin? *

Postal Address

Please use title case, e.g. (Optometry Australia)

Company/Practice Name

Position

Address line 1 *

Invalid value

Address line 2

Postcode *

Invalid value

Suburb *

State *

Invalid value

Primary Contact Details (Include Area Code)

Enter either Phone number or Mobile Number.

Phone Number (Landline)

At least one Phone Number is needed.

Mobile Number

At least one Phone Number is needed.

Fax

Email Address *

Primary Email has already been used

Website (Include http:// or https://)

Do you have a practice address?

Primary Practice Address (Australia Only)

Please use title case, e.g. (Optometry Australia)

Company/Practice Name *

Position *

Address Line 1 *

Address Line 2

Postcode *

Suburb *

State *

Phone(Landline) *

Mobile *

Fax

Email *

Website

Do you want to enter home address? (you must complete this if it is your preferred contact detail)

Home address

Please use title case, e.g. (Collin Street)

Address Line 1 *

Address Line 2

Country *

Postcode *

Suburb *

State *

Phone

Mobile *

Email *

Do you want to enter another address? (e.g. PO Box address)

Other address

Please use title case, e.g. (Collin Street)

Company/Practice Name

Address Line 1 *

Address Line 2

Country *

Postcode

Suburb *

State

Phone

Mobile *

Email *

Fax

Preferred Contact Details (where you want your communications go to)

Practice Address

Home Address

Other Address

Review Your Application

If you print this from the browser, please set the LAYOUT/ORIENTATION mode to LANDSCAPE and PAPER SIZE to A4 or Shrink the layout to fit.

You are about to submit the following details:

Personal Details

In which state is your primary practice located

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Title

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First Name

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Middle Name

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Surname

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Preferred Name

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Gender

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Date of Birth

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Primary Email

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Have you been a member with us?

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I am of Aboriginal or Torres Strait Islander origin.

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Primary Practice Address

Company/Practice Name

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Position

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Address Line 1

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Address Line 2

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State

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Suburb

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Postcode

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Phone

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Mobile

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Fax

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##primaryPracAddress_email##

Website

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Home Address

Address Line 1

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Address Line 2

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State

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Suburb

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Postcode

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Phone

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Mobile

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Other Address

Company/Practice Name

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Address Line 1

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Address Line 2

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Country

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Postcode

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Suburb

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State

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Phone

##otherAddress_phone##

Mobile

##otherAddress_mobile##

##otherAddress_email##

FAX

##otherAddress_fax##

Preferred Contact Address

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Professional Information

Registration No

##professionalInfo_regno##

Upload Document

##professionalInfo_uploaddoc##

Are you Therapeutically Qualified?

##therapeutically_qualified##

Other Language 1

##professionalInfo_otherlangone##

Other Language 2

##professionalInfo_otherlanguagetwo##

Other Language 3

##professionalInfo_otherlanguagethree##

CPR Accredited

##professionalInfo_cpracc##

Child Safety Cert.

##professionalInfo_childsafertycert##

Compliance Consense

##professionalInfo_complianceconsent##

Qualification

First Qualification Name

##qualification_firstqualname##

Year Obtained

##qualification_firstDateObtained##

Institution

##qualification_firstinstitution##

Second Qualification Name

##qualification_secondqualname##

Year Obtained

##qualification_seconddateobtained##

Institution

##qualification_secondinstitution##

Services Provided

##specialinterest_list##

Equipment

##equipment_list##

Preferred option for meeting-related communications

I would like to continue to receive meeting-related communications

##meetCommFormat##

Opt In

Opt in to receiving printed correspondence from OA National eg. Optometry Connection magazine

##opt_inpubfromoa##

Opt in to receiving Third Party correspondence

##opt_inpubfromthirdparty##

Opt in to receiving correspondence from state office

##opt_inpubfromindividualstates##

Membership Type

##memType##

Total Amount

##totalAmt##

Code of Ethics

Payment Summary

You are paying for

Donation amount

Total

GST

Contact Details

Retrieve Your Application

You can save your progress and get back to it at a later stage.

Membership Application Form

In which state is your primary practice located.

Membership Category

Personal Details

Are you of Aboriginal or Torres Strait Islander origin? *

Postal Address

Primary Contact Details (Include Area Code)

Do you have a practice address?

Primary Practice Address (Australia Only)

Do you want to enter home address? (you must complete this if it is your preferred contact detail)

Home address

Do you want to enter another address? (e.g. PO Box address)

Other address

Preferred Contact Details (where you want your communications go to)

Professional Information

Qualification

Services Provided

Equipment

Referees

Preferred option for meeting-related communications

Opt in/out

Review Your Application

Personal Details

Primary Practice Address

Home Address

Other Address

Preferred Contact Address

Professional Information

Qualification

Services Provided

Equipment

Referees (Only required by Optometry Western Australia)

Preferred option for meeting-related communications

Opt In

Membership Type

Code of Ethics

Donation

Payment Summary

Payment Method

Select Name and Address to appear in the Invoice/Receipt