Virginia Society of Ophthalmic Medical Personnel Inc.
 
 

Year 2004 Membership Application

                                               Print Out & Mail In 
                   Please Print 
                      Name:______________________________________________ 

                      Certifications:________________________________________ 

                      Certifying Agency:____________________________________ 

                      Home Address:_______________________________________ 

                      ___________________________________________________ 

                      Zip Code:______________________ 

                      Telephone:_______________ Home _________________Office 

                      Fax:_____________________ e-mail______________________ 
 
.....................Practice Name:_____________________________________
 

Which category best describes your major professional activity? (Select one)
______Ophthalmic Assistant 
______Ophthalmic Technician 
______Ophthalmic Technologist 
______Ophthalmic Photographer 
______Contact Lens Technician 
______Office Manager 
______Receptionist 
______Billing Clerk
______Registered Nurse 
______Practical Nurse 
______Orthoptist 
______Ocularist 
______Optician 
______Optometrist 
______Secretary 
______Other (Describe)______________
mail to: 

VSOMP
c/o Kelly Steele
1475 Johnston-Willis Drive
Richmond, VA 23225
 

VSOMP Dues are $25.00
per member, per calendar year. 

Please enclose a $25.00 
check made out to VSOMP

(At this time the VSOMP does not accept credit cards)