Student Membership Application

Pennsylvania Optometric Association and Pennsylvania Optometric Student Society (POSS)

Please return completed application to POA, 218 North Street, Harrisburg, PA 17101. If you have any questions, please contact the POA office at [email protected] or (717) 233-6455. For more information, visit www.poaeyes.org. Gifts and/or dues payments to POA and/or POSS are not deductible as charitable contributions for federal income tax purposes; however, they may be deductible as business expenses under other provisions of the Internal Revenue Code. Consult your tax advisor.

Please type or print. Date Full Name Male Female Present College Address Home Address

E-Mail County (Home) To protect our members' privacy, POA will not share, sell or otherwise distribute member e-mail addresses.

Phone (College) Phone (Home) Preferred Mailing Address: College Home

Date of Birth Maiden Name (If applicable) Spouse’s Name Optometric College Year of Graduation In which state(s) do you expect to practice? Club or Organization Affiliations POA BY-LAWS: ARTICLE II – Membership and By-laws and who are otherwise qualified under the Section 13. Student Society Membership provisions of these by-laws. (a) Student Membership is granted to those optometric (b) The Society may exclude, suspend, or expel member as students who are members of the student society provided in these By-laws or as otherwise prescribed by recognized by these By-Laws. Student Membership shall law. not continue after the end of the calendar year in which the (c) Membership shall not continue after the end of the student member graduates. calendar year in which the student graduates. (b) Student members shall not be considered in accrediting (d) Membership will cease to exist immediately if the member any affiliated society’s delegate votes in the House of discontinues, withdraws, or is expelled from a college or Delegates; school of optometry. (c) Student members shall pay dues in accordance with these Section 3. Active Membership By-Laws; (a) Students attending the Pennsylvania College of Optometry (d) Student members shall have the privilege of the floor in the are eligible for Active membership in this Society. House of Delegates; (b) Active members may hold elective office in this Society (e) Student members may not hold elective office in this after membership of one (1) year. Association (c) Active members shall pay dues in accordance with these POA BY-LAWS: ARTICLE IV – Voting by-laws. Section 4 (d) Active members shall have voting privileges. (b) The affiliated student society shall have one (1) delegate (e) Active members shall have the privilege of the floor. vote. (f) Active members shall be eligible for appointment to POA POA BY-LAWS: ARTICLE VIII – Dues Committees. Section 1. General Provisions Section 4. Associate Membership (c) The annual dues for Student Members shall be established (a) Students attending a school or college of optometry other by the Board of Directors in consultation with the student than the Pennsylvania College of Optometry are eligible society. for Associate membership in this Society. (b) Associate members may not hold elective office in this POSS BY-LAWS: ARTICLE I - Membership Society. Section 1. General Principles (c) Associate members shall not pay dues to this Society. (a) Membership in this Society is open to optometric students, (d) Associate members shall not have voting privileges in this regardless of state of residence or optometric institution Society. affiliation, who are interested in the purposes of this (e) Associate members shall have the privilege of the floor. society, who are willing to subscribe to this Constitution

Signature of Applicant ______