Member Renewal Form Your 2020 membership is now due. As the Executive Board needs to maintain a current data base, it is important to take a few minutes to answer ALL the questions below.Name*Place of Business*Business Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Phone*Cell Phone*Home PhoneEmail Address* Dues INITIATION FEE: $50.00 CERTIFIED/REGULAR: $100.00 ASSOCIATE: $50.00 STUDENT: $35.00 (No initiation fee required)Membership StatusCERTIFIED – ABO, NCLE, OR State Licensed opticianREGULAR – Registered Dispensing Optician, living and/or working in the state of New HampshireASSOCIATE – Any other person concerned with advancing the objectives if this organizationSTUDENT – Anyone enrolled full-time in an ophthalmic dispensing program at an accreditedTotal $0.00 Optical MembershipsABO CERT #*NCLE CERT #*Do you have a valid license in any other state?*YesNoWhere?*EmailThis field is for validation purposes and should be left unchanged.