Emphasis: Pediatric Optometry

American Academy of Optometry - DIPLOMATE CANDIDACY

Date _________________________________________

Name ________________________________________

Office Address _________________________________

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Phone (___) ___________________________________

Fax (___) _____________________________________

Email _________________________________________

Home Address _________________________________

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Phone (___) __________________________________

Fax (___) ____________________________________

Where do you want mail sent? Office [_] Home [_] (check one) 

ATTACHED IS:

[_] Mode of Practice Information Sheet (Clinical Diplomate only)
[_] Curriculum Vitae [to include: professional education, professional experience (clinical & teaching), professional affiliations, presentations, publications, honors and awards, community/professional service]
[_] Check for $100.00, made out to the American Academy of Optometry

I understand that I have five (5) years, which includes the next five (5) Academy meetings, to complete the requirements for the Pediatric Optometry Diplomate. If I have not successfully completed these requirements after this time, I will have to completely start over if I plan to continue in the program.

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Signature

** Please return this application form, with attachments, to:

Binocular Vision and Perception Section Diplomate Program
American Academy of Optometry
6110 Executive Blvd., Suite 506
Rockville, MD 20852
301-984-1441, fax 301-984-4737, email

PEDIATRIC OPTOMETRY
MODE OF PRACTICE INFORMATION

Approximately how many of the following types of diagnostic evaluations do you participate in each month?

Approximately how many of the following types of diagnostic evaluations have you performed in the last two years?