Prevention of Blindness Society...

PROFESSIONAL MEMBER HONOR ROLL

Legal Notices, Disclaimers

Directory of Vision Health Care Professionals

(COMPLETE THIS FORM FOR EACH OFFICE. DUPLICATE AS NEEDED.)

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 TO:

PREVENTION OF BLINDNESS SOCIETY

OF THE METROPOLITAN AREA
1775 Church Street, N.W.

Washington, DC 20036