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