Optometry Australia

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

In which state will you apply for.

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 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 (Landline)

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)

Home Address

Other Address

Qualification

First Qualification Name *

Institution *

Expected Completion Year *

Opt in/out

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

Opt in to receiving correspondence from state office

Opt in to receiving Third Party correspondence (Your personal details will not be provided to 3rd parties.)

Review Your Application

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You are about to submit the following details:

Personal Details

In which state will you apply for

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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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Home Address

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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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Country

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Phone

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FAX

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Qualification

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Institution

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Expected Completion Year

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Preferred option for meeting-related communications

I would like to continue to receive meeting-related communications

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Opt In

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

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Opt in to receiving Third Party correspondence

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Opt in to receiving correspondence from state office

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Membership Type

Student

Register for a Student Membership

In which state will you apply for.

Personal Details

Are you of Aboriginal or Torres Strait Islander origin? *

Postal Address

Primary Contact Details (Include Area Code)

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)

Qualification

Preferred option for meeting-related communications

Opt in/out

Review Your Application

Personal Details

Home Address

Other Address

Preferred Contact Address

Qualification

Preferred option for meeting-related communications

Opt In

Membership Type

Code of Ethics