Membership Registration

KARNATAKA OPTOMETRY ASSOCIATION ® 
MEMBERSHIP FORM

(To be filled legibly, in BLOCK LETTERS and to be sent to Present Secretariat)
Expert Optics. #12 Nehru Main Road, Yadava Layout, Kammanahalli, Bangalore - 560084.
Please Enroll me as Life Member / Associate Member
Life Member in KOA Associate Member in KOA
(Validity for 3 years)		 Student Membership
Rs. 1000/- Rs. 500/- Rs. 300/-
In case of Principal: (ONLY FOR STUDENTS)
DETAILS OF DEMAND DRAFT
 
In favor of KARNATAKA OPTOMETRY ASSOCIATION Payable at Bangalore.
Please enclose 2 stamp size color photographs for I.D. Card
Documents Required
  1. Mark-sheet of 10th & 12th standard (high school / sr. secondary school).
  2. Attested copy of diploma/degree awarded from the optometry institute.
  3. Each year’s mark-sheet from the optometry institute.
  4. The affiliation/registration of your optometry institute from the respective state medical faculty.
  5. Introductory reference  of your senior/ junior who is already a life member  of any association (with details of his/her LM number)
  6. Status of your university/institution whether it is a central university /state university/ deemed university/private University. This is for reference only and not mandatory.
  7. Photocopy of Demand Draft should also attach with Application form.
  8. The Application form should be dispatched in A-4 size envelope so that it could not be torn down.
  9. Approval/ Recognition   letter of Degree / Diploma in Optometry / equivalent   & session of course from University/DEC/UGC/States Medical Faculties/Central or State health department or Directorate /Education department of Govt. of Central or State etc.  
  10. I  took oath that my  university / board, my course / subject  & session /duration of  diploma/degree 
  11.  Approved / recognized at time of admission. I am only/sole responsible  status of education
Terms and Conditions
  • That the information provided by me in the Life Membership Form is true and correct.
  • That there is no legal/medico legal case pending against me in any court of India/abroad.
  • That in future, I shall not hold the Karnataka optometry association responsible for any of my misconduct during my practice as an optometrist or as an individual. However it is entirely the discretion of KOA office to assist me /support me in case such situation arises in future.
  • That I shall immediately intimate the KOA office about my change of name/corresponding address and phone number as and whenever I do so in future.
  • *Please enroll me as a member of the Association and allow me to deposit the registration/admission fee as per its rules and regulations.
  • Application must be typed or neatly written (In block letters)
  • *K.O.A. reserves right to accept or reject this application.