Member "Survey/Project Request" Application

Personal Information
First Name:
Last Name:
Address:
 
City: State: Zip:
Phone:
Email:
Representative Organization
 (student/college, faculty, committee, member)

Survey/project Information
What is the purpose of your survey/project?
How will the results of this survey/project benefit the membership or the association?
How do you propose the survey/project results be published? (A copy of the survey/project results is required to be submitted to the MOA prior to publication.)
How does this survey contribute to the MOA Mission Statement?
Method of survey/project distribution (please check.)
Mail $50 For MOA Labels
 (Surveyor responsible for printing and mailing survey.)
MOA Exhibit Booth - Fall/Winter/Summer
The Michigan Optometrist magazine
E-blast
Fax
Survey/project distribution date: ?
Survey/project submission deadline date: ?
Comments:
   - denotes required fields