I would like to be listed in POB’s Directory of Vision Care Professionals.

   I would not like to be listed in POB’s Directory of Vision Care Professionals.

Name:  _______________________________________________________________________

Practice Name:  ________________________________________________________________

Address:  _____________________________________________________________________

______________________________________________________________________________

City: ________________________ State:  ______________ Zip:  ________________________

Phone:  _______________________________________________________________________

Please list any areas of training:  ____________________________________

Professional Member Listing  (Please include additional information):

Fax:  _______________________________________________________________________

Email:  _______________________________________________________________________

Website:  _____________________________________________________________________

PLEASE RETURN FORM WITH
YOUR $100 CONTRIBUTION TO:

PREVENTION OF BLINDNESS SOCIETY
OF METROPOLITAN WASHINGTON
1775 Church Street, NW
Washington, DC 20036