I certify that this applicant is a full-time educator of the school or college and is not engaged in the practice of Optometry more than 16 hours per week.
I certify that I am familiar with the Codes of Ethics of the American Optometric Association and the Virginia Optometric Association; that I have read any rules of practice, resolutions or Board of Trustees rulings, if any, that accompanied this application; am cognizant of their meaning and provisions; and agree that any violations thereof or the willful giving of false information to the Board of Trustees shall constitute grounds for the rejection of my application or, upon proof of violation after my acceptance as a member, for such action as the Board of Trustees may take under the Constitution.
Unless otherwise noted with proper and full explanations (including summation of charges and actions), I have never been found guilty, sanctioned or disciplined by the Virginia Board of Optometry or any other legal entity for violation of any law or regulation governing the practice of optometry in Virginia or in any other State or Territory of the United States of America.
Fully appreciative of my responsibility to this Association, to my profession, and to the public which it serves, I hereby place my signature to this application.
Note: Dues are not tax deductible as a charitable donation or contribution, but may be tax deductible as a business related expense.
