2019 MOA Partner Program Registration

Complete the information below to support the profession of optometry through the MOA Partner Program.

Company Name:
Partnership Contact Person:
Title:
Phone:
Email Address:
Company Address:
 
City: State: Zip:
Company Website:
Products/Services:

Please choose your desired partnership level:

Collaborator - $10,000
Teammate - $7,000
Associate - $5,000
PLEASE NOTE: If your company requires additional paperwork, please let us know and we will happily comply with those requirements. Questions? Contact Jamie James, MOA Director of Communications & Marketing at jamie@themoa.org or call the MOA office at 517.482.0616.

Modification:

If you would like to propose modifications to the Partner Program package you have selected, please detail the modification below and we will review and be in touch shortly.


Electronic Signature:

I agree to the terms, policies, conditions and rates set-forth by the Michigan Optometric Association.

E-signature:
   - denotes required fields