Registration Form for Doctors 2008 OD REGISTRATION FORM Name: Address: City/State/Zip: Phone: E-Mail: Spouse/Guest: FEES 23-Hour Therapeutic Pharmaceuitcal Didactic Course   Before 2/ 1 After 2/ 1   AKOA Member $300 $400 $ AFOS/AOA Member Practicing in AK $400 $500 $ AOA Member # $800 $900 $ Non-AOA Member $1300 $1400 $     Optometry Residents or Students $0 $0       7-Hour Ocular Therapeutic Injection Lab AKOA Member $100 $150 $ AFOS/AOA Member Practicing in AK $150 $200 $ AOA Member # $500 $600 $ Non-AOA Member $700 $800 $       Total: $ PAYMENT PROCESSING Total Enclosed $ Check Enclosed Visa MasterCard American Express Discover Credit Card Number: __________________________________________________ Exp. Date: ___________ Cardholder's Name: _______________________________________________________________________ Address (as shown on credit card statement) _____________________________________________________ _______________________________________________________________________________________ Signature: ___________________________________________________________ Date: ________________   Submitting Form: 1. Fill in the appropriate blanks. 2. Print Form 3. Complete Payment Processing Section 4. Mail or Fax to: Alaska Optometric Association 1689 C Street, Ste 222 Anchorage, AK 99501 Fax: 907-272-7532 Phone: 907-770-3777     PLEASE NOTE: If you are completing this course in an effort to obtain an updated TPA Endorsement, all 23 hours of the Oral Didactic Course and all 7 hours of the Injection Course must be taken in their entirety. Doors to the course will be closed at the start of each session and late comers will not receive TPA Amplification credit. An optional test will be provided at the conclusion of the course.
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