OD REGISTRATION FORM
Last Name:
First Name:
Address:
City: ST: Zip:
Phone: Fax:
E-Mail:
FEES
*The registration fees above include education, food, and exhibit hall for registrant only. Additional fees may apply for guests.
PAYMENT PROCESSING
Total Enclosed $
Credit Card Number ____________________________________
Cardholder's Name _____________________________________
Address (as shown on credit card statement) ______________________________________
Signature _______________________________________________________
SUBMITTING FORM
1. Fill in the appropriate blanks.
2. Print Form
3. Complete Payment Processing Section
4. Mail or Fax to:
Alaska Optometric Association 1501 West 36th, Ste 230 Anchorage, AK 99503 Fax: (907) 272 7532
