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Student Membership Application

(* Denotes Required Fields)

Basic Information

First Name: *
Last Name: *
Date of Birth (MM/DD/YY) *
Email Address: *
Maiden Name:
Spouse's Name:
Gender: *

Home Information

Home Address: *
City: *
State: *
Zip Code: *
Home Phone or Cell Phone: *

Education & Additional Information

Optometry School Attending: *
Expected Graduation Date (MM/YY): *
Foreign Languages Spoken:
Please allow 1-2 weeks for processing. Questions? Call (860) 529-1900 or email: info@cteyes.org


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Connecticut Association of Optometrists
35 Cold Spring Road, Suite 211
Rocky Hill, CT 06067
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Phone (860) 529.1900
Fax (860) 529.4411
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