Ophthalmic Career Progression Program

Application for Enrollment

 

This application form is for enrollment into the Ophthalmic Career Progression Program. It is not a contract agreement. It is to be sent to the Academy along with a nonrefundable application fee of $50.00.  Incomplete applications will be returned.

 

Information MUST be TYPED or PRINTED clearly, in ink.

1. Title   p Mr.  p Mrs.  p Ms.  p Miss

2. Name _____________________________________________________________

2. Date of Birth ____________________  4.Social Security # __________________

5.  Home Address _____________________________________________________

6. City _______________________________  7. State _____  8. Zip ____________

9. Home Phone  (___)_____________ 10. Business Phone (___)_______________

11. Email: __________________________________________________________    

12. Company Name/Address ___________________________________________

13. City ______________________________ 14. State ____ 15. Zip ___________  

16.  Number of years employed as an optician (if any) _____________     

17.  Circle highest education:  GED     H.S.     College  1 2 3 4 5 6

 

18.  I verify that the education information as well as all other information provided above is true and accurate. I certify that I have read and understand all portions of this application and believe myself to be in compliance with all admission policies of the Ophthalmic Career Progression Program for which I am applying.

___________________________________________________________

 

19.  I VERIFY THAT THE INFORMATION PROVIDED BY THE ABOVE APPLICANT IS ACCURATE.

___________________________________________________________

                                                                                                                          

Method of Payment (for application fee):   p Check   p Visa   p MC  p Amex  p  Discover

 

Card # ________________________________________Exp Date ______________

Cardholder’s Name: _________________________________________

 

Academy Member?  p Yes    p No

 

Completion Requirements

Completion of the Academy’s OCPP Home Study Program requires:

 

1.       Successful completion of monitored multiple-choice examinations on each volume and a final examination. Students must score 70 percent or higher on each examination.

2.       Demonstrated clinical competency as attested to by his/her sponsor.

 

 

 

Sponsor Registration Agreement

 

(TO BE SIGNED BY YOUR SPONSOR)

 

Mr., Mrs., Ms. ___________________________________________ is known to me to be a responsible individual. I understand that this individual is applying for enrollment in the Ophthalmic Career Progression Program (OCPP) of the National Academy of Opticianry. I agree to be available to answer questions, administer tests and assist in other aspects of the home study course as they arise.

 

I am acquainted with and have had the opportunity to observe the applicant’s dispensing experience for ______ months, if any.

 

I recommend this individual for admission to the Ophthalmic Career Progression Program.

 

______________________________________________     ___________________

Signature of Sponsor                                                                Date

 

_____________________________________________     ____________________  

Type or print Sponsor’s name clearly                                        Position/title

 

______________________________________________   ____________________

Employer                                                                                  Business Phone

 ________________________________________________________________________________

Street or PO Box                                                                    

_________________________________________________________________________

City                                                        State                              Zip

 

SPONSOR’S CREDENTIALS

 

Qualifications: (Check as many as apply)

 

p Master in Ophthalmic Optics

p American Board of Opticianry certified (ABO)

p Opticianry State Licenses ___________________________________________________

p Ophthalmologist (M.D.)        

p Optometrist (O.D.)

p Other (please specify)________________________________________________________