New Member Registration Form Your InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Cell Phone*Home PhoneBusinessPlace of Business* Business Phone*Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CertificationsDispensing experience and training ABO # NCLE # State License # Other related certifications or memberships DuesINITIATION FEE: $50.00 CERTIFIED/REGULAR: $100.00 ASSOCIATE: $50.00 STUDENT: $35.00 (No initiation fee required) Type of Membership* CERTIFIED – ABO, NCLE, OR State Licensed optician REGULAR – Registered Dispensing Optician, living and/or working in the state of New Hampshire ASSOCIATE – Any other person concerned with advancing the objectives if this organization STUDENT – Anyone enrolled full-time in an ophthalmic dispensing program at an accredited Initiation fee of $50 has been added to all memberships except StudentTotal $0.00 I have read and understand all of the preceding questions to this application, and hereby warrant each of the preceding answers to be true. I do hereby agree to do all within my power to help promote the purpose and beliefs of this organization, faithfully, in accordance with the by-laws, as outlined by the New Hampshire Opticians Society.Type name for signature* Date* MM slash DD slash YYYY
