4. Home phone, e-mail, fax __________________________________________________
Which address do you prefer for correspondence ? Bus ___ Home ___
5. Date of birth ______________
6. Citizenship _______________
7. What is your current situation?
___ Practice of optometry ___ Solo practice ___ Associate or group practice ___ Employed by another ___ HMO ___ VA ___ School of Optometry ___ Military ___ Other (specify) _________________________
___ Student of optometry at ________________________ Anticipated graduation date: ____________
___ Not currently practicing optometry. ___ Retired optometrist ___ Other professional (specify) _________________________________________
8. Alumni of __________________________ Year of graduation ________
9. Marital status: single ___ married ___ widowed ___ separated ___
divorced ___
Full name of spouse ___________________________
Ages of children __________________
10. Foreign language(s) you can read ________________________________________
Foreign language(s) you can speak _______________________________________
11. Current church affiliation:
Church name ______________________
Denomination _______________________
City where located __________________
12. Briefly tell when and how you received Jesus Christ as your Savior.
13. List any experience you have had in Christian mission work. Include
country visited, when you went, with what organization, and purpose for the trip.
15. What personal involvement do you anticipate in FCO, International?
___ financial support through membership dues ___ leadership role at local or state chapter ___ involvement in local chapter ___ donation of ophthalmic equipment ___ volunteer service in a missionary clinic ___ helping found and support a missionary clinic ___ discovering where I can best serve in the organization ___ other (specify)
16. List the names and addresses of other Christian optometrists whom you
feel would be interested in FCO, International, and for whom FCO can list you as a
reference.
If you have read and are in agreement with the purposes and beliefs of
FCO, understand the requirements for membership, and acknowledge Jesus Christ
as your Lord and Savior; and on the basis of these points you desire and are
qualified for membership in FCO, International, please so indicate by signing
below.
_____________________________
_________________
Signature
Date
Please return this form to:
FCO, International
1494 Pine Lane Drive
Cantonment, FL 32533
The suggested membership contribution is $180 per year (no cost to students or
residents), and can be made annually or in monthly, quarterly or semiannual
payments. This is only a suggested amount. Suggested contributions for recent
graduates are $50, $85, $125, $180, and $225 for the first five years,
respectively. Your initial contribution should accompany this membership
application. All contributions to FCO, International, Inc. are tax
deductible.