The Society Of  Dispensing Opticians Of Kentucky Membership Form

(This is not an "online" form, it needs to be filled out,  printed and mailed)

MEMBERSHIP OR RENEWAL              Date:

Name:

Kentucky Opticians License Number:

Social Security Number:

County of Residence:

BUSINESS INFORMATION

Name of Employer:

Title or Position:

P.O. Box or Street:

City, State, Zip Code:

Business Phone Number (Area Code):

HOME INFORMATION

P.O. Box or Street & Apt. Number:

City, State, Zip Code:

Home Phone Number (Area Code):

E-Mail Address:

Type of Membership (Check one that applies)
Active Licensed Member New: $60.00 Renewal: $55.00
Associate Member (Apprentices) New: $35.00 Renewal: $25.00
Out of State Associate New: $35.00 Renewal: $25.00
Vendor Member New: $35.00 Renewal: $25.00
I am authorized to buy optical goods for my company Yes No
Mail form to and make check payable to:
The Society Of  Dispensing Opticians Of Kentucky
Lexington, Kentucky 40524-4214
(859) 278-6026
   Note: THIS FORM MUST ACCOMPANY CHECK OR MONEY ORDER.
It is your responsibility to notify the Society of changes in employment and or address.
Membership year runs from July 1 through June 30 of each year