New Member – Elite Divas Registration New Member Registration Form Today's Date(Required) MM slash DD slash YYYY Personal InformationName(Required) First Last Email(Required) Mobile Phone(Required)Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Professional InformationWhere did you go to Optometry School?(Required) What year did you graduate?(Required) What is your practice modality?(Required) Private Practice Owner Private Practice Associate Corporate Lease Owner Corporate Lease Associate Independent Contractor OMD Group Practice Associate VA Optometrist Industry Leadership Position Academia Please select one option.Why are you joining Optometry Divas?(Required) To connect with other women ODs To get personal development resources For Business skills development For Leadership skills development For the fun educational events Please select one option.Credit Card Number(Required) Expiration Date: MM/YYYY(Required) SEC 3 Digit Code(Required) Is the billing address the same as your mailing address?(Required) Yes No Billing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Enter your credit card billing address below.Consent(Required) I agree to the privacy policy.Your annual membership price will be automatically drafted from you debit or credit card each year. In completing this form and purchase of this membership, I authorize Optometry Divas to charge my credit or debit card the monthly subscription amount listed above every month until I cancel. I understand that I am responsible to cancel my subscription to prevent further charges. I further understand that once a charge has been processed, it will not be refunded. If through no fault of ours, your payment account does not contain sufficient funds to complete the transaction, or your payment account or credit card does not otherwise permit the transaction to be executed, you will be charged a $35 insufficient funds fee. We will contact you to update your account with a working payment method. You have the right to receive a notice in the event that we make any change to the terms and conditions of your membership that will vary the amount to be periodically billed to your account specified above. Except as expressly provided herein, we may modify our services or the terms and conditions of this Agreement at any time without notice and such modifications shall be deemed effective immediately upon making such changes.
