GENERAL INFORMATION Full Name * Title E-Mail * Phone Number (with country code) Whatsapp (with country code) * Favourite contact method * WhatsappE-Mail Education beyond High School * Insitution - Degree - Date Professional Certification/Fellowship/Licenses * Institution - Description - Designation - Date Professional Organization/Society Memberships (including IAOMC) * Organization - Date joined - StatusPROFESSIONAL ACTIVITIES How many hours of post graduate education have you completed in the last 12 months? * Institution - Hours - Topic Please list the approximate percentage of time you engage in * Private optometric clinical practice: Private ophthalmologic clinical practice: Governmental/Hospital: Educator: Other (please describe): Employment history since graduation * Company/Institution and location - Position - DateMyopia Management experience How many myopia management cases do you see in your practice each month? * Do you own a Biometer? * Yes No Do you have access to a biometer? * Yes No If Yes, which one? List all the Orthok Lenses/Myopia Control lenses you have used: * Manufactur/lens - Approximate n° fitted -Level of proficiency: 1 minimal – 5 expertPAST HISTORY Please answer to all questions * YesNo Have you been convicted of a felony in any jurisdiction in which you hold a license or right to practice? * Have you been convicted of a felony in any jurisdiction in which you hold a license or right to practice? - Yes Have you been convicted of a felony in any jurisdiction in which you hold a license or right to practice? - No Have you ever had your license revoked, suspended, received an official reprimand/warning? * Have you ever had your license revoked, suspended, received an official reprimand/warning? - Yes Have you ever had your license revoked, suspended, received an official reprimand/warning? - No Had a complaint filed against you with your state/national professional or consumer organization? * Had a complaint filed against you with your state/national professional or consumer organization? - Yes Had a complaint filed against you with your state/national professional or consumer organization? - No If yes, please explain MOTIVATION Please provide a one page document detailing why you wish to pursue an IACMM and what you plan to do for the Academy after attaining your certification. Please upload the file Upload Use your Full Name as file name. More informationFiles must be less than 2 MB. Allowed file types: jpg png pdf doc docx. CERTIFICATION OF UNDERSTANDING BY SUBMITTING THIS FORM If accepted for candidacy, I understand: If I fail any portion of the test, I may repeat the test once at no change but if I fail twice I must reapply and pay a new fee. If I do not pass any portion of the testing I have two years from the application date to attain a passing score or I will need to reapply and pay the full application fee again. I certify that the answers I have provided in the above application are accurate and truthful. I understand that if I have provided any false information, I will be banned from sitting for the exam. I understand that as part of the application process, my professional background will be investigated through the use of a colleague interview, social media, etc. I give my permission for this to occur. I certify that I have: Been a continuous member of a IAOMC Section, In this case EurOK, for at least one year I will have to continue to be member to EurOK and renew annually my membership in order to maintain the certification and use the title. Submit
