NJSOP Membership Application

Please complete the following information for membership consideration.
All fields required, if applicable. No payment will be collected at this time.
You will be billed upon acceptance of your application.

CONTACT INFORMATION:

First Name
Middle/Maiden (if applicable)
Last Name
Email
Date of Birth ?
Main Office Address:
Company
Address
City State Zip
Phone Fax
County
Branch Office #1:
Address
City State Zip
Phone Fax
County
Branch Office #2:
Address
City State Zip
Phone Fax
County
Home Address:
Address
City State Zip
Phone
County
Preferred Mailing Address:
Would you like to receive TEXT MESSAGES from NJSOP about events, cancellations, and other
important information?
If YES, please provide your cell phone number below:
Cell Phone

ADDITIONAL INFO:

Sex:
Marital Status:
Spouse’s Name:
Date of Original Licensure: ?
State of Original Licensure:
Optometry School Attended:
Graduation Date: ?
Date of NJ License: ?
NJ License #’s: OA
TPA # (if applicable) TO
OM #
ARBO #
Have You Been Previously Licensed in Another State?
If Yes, Please Indicate State(s) and Year(s) below:
 
Has your License Ever Been Revoked, Annulled or Suspended?
If Yes, please explain below:
 
Were You Ever A Member of Another State Association?
If Yes, Please Indicate Which State(s) and Year(s) below:
 
Were You Ever a Member of the NJSOP?
If Yes, please state what year(s)
 

MEMBERSHIP CATEGORY:

Click Here to view a description of each membership category before choosing the one that applies to you below.
 

SPECIAL INTEREST AREAS: (check all that apply)

  Contact Lenses Pediatric Orthokeratology
  Medicare PAR Provider Vision Therapy Accepts Medicaid
  Industrial Low Vision Prosthesis
  TPA Certified Laser Center Affiliation Geriatric
  Home Visits Neuro-Opto Rehab

LOCAL SOCIETY AFFILIATION:

Your membership is contingent upon a local society affiliation. Please select the local society with which you wish to affiliate below. The NJSOP office will notify the local for you. Keep in mind, you have the option to switch your affiliation at a later date if you wish.

OPTOMETRY'S OATH of PRACTICE

Click Here to read Optometry's Oath of Practice before signing below.
I have read Optometry's Oath of Practice and hereby make application for membership in the New Jersey Society of Optometric Physicians, the American Optometric Association and my chosen local society. I obligate myself to return the certificate of membership to the Society should I ever resign or be dropped from the roster or in the event that my membership is terminated for whatever reason. I agree to abide by the NJSOP Constitution and Bylaws and to adhere faithfully to the Optometric Oath. By agreeing to be a member of NJSOP, I agree to receive all forms of communication from NJSOP, including but not limited to mail, email, fax, texts & phone.
Were you referred by a current NJSOP member? If so, who?
 
   - denotes required fields