Opticians Association of America

Guild of Prescription Opticians of America

Guild Application for Accreditation

Firm	Address
City	State	Zip
Tel	OAA Rep Name

You MUST be an OAA Firm Member.

OAA Firm Member since

This is for a :

New Application

Change of Ownership Applcation

This Firm is :

Individually Owned

Partnership

Corporation

	First Name	Last Name	Title
Name of Officers

Activities of the Firm include:	Spectacle Fitting & Dispensing	Laboratory Facilities
	CL Fitting & Dispensing	Including Surfacing
	Artificial Eyes	Including Edging
	Hearing Devices	Including Assembly

Does this firm operate any non-optical departments Yes No

If yes, please specify %Optical %Non-Optical

This firm operates in the state(s) of
Number of Locations	ABO certified employees	Yes	No
Number of Employees	NCLE certified employees	Yes	No
Number of Dispensers	State Licensed employees	Yes	No

Does this firm have a wholesale optical depatrment	Yes	No
If answer is yes above, is it a seperate corporation	Yes	No
Does it engage in any form of of agency dispensing for doctors	Yes	No
Does it compound complete glasses for doctors to dispense	Yes	No

Does any partner, owner, officer, employee, or other person directly or indirectly
associated with this firm, examine eyes and/or prescribe eyeglasses	Yes	No

Are any refractionists associated with this firm as a partner, owner,
stockholder, directly, or indirectly or in any manner	Yes	No

FEE REQUIREMENTS - Send guild accreditation fee with this application.
The annual accreditation of $100 + $5 for each branch location.
If joining OAA at the same time, one check for total amount is acceptable

ACKNOWLEDGEMENT

I certify that having read and understood the Code of Ethics, my application does not conflict
with the membership requirements, and I will uphold the Code of Ethics of the Guild of
Prescription Opticians of America, and I will pledge that any and all branch locations will
exemplify the Guild of Prescription Opticians of America.

Signature 1)______________________________________________________Date_________

Sponsor 1)___________________________________________________________________

Sponsor 2)___________________________________________________________________
Two current Guild Members are requested to sponsor new Guild Members

To mail, or fax this form, complete the form above, then click "Print Page".

Mail to:
THE GUILD: 4064 E Fir Hill Drive, Lakeland, Tennessee 38002; Fax 901.388.2348