Profile Information

Registering as an International (Outside of the US, Mexico, and Canada) Guest? Please use this form: International Profile

SECO - Create a new profile

  ** = Required Field
Login Name: **
Password: **
Confirm Password: **
Type:**

OD: I am an optometrist, ophthalmologist, optometrist resident, or optomerty student.
AOP: I am an optician, paraoptometric, ophthalmic technician, or administrative personnel working within an optometric or ophthalmic practice; or, I work for an optometric organization.
OTH: I am a spouse or child.
Subcategory:
Select a type to reveal the list of subcategories
Prefix:
First Name: **
Middle Initial:
Last Name: **
Suffix:
Professional Title: (i.e. O.D., F.A.A.O., etc.)
Badge Name: (as it will appear on any name badges)
Gender: **
Employer/Company Name:
Optometry School: (if applicable)
Class Year: **
Primary Practice State/Province:  (if applicable)
Years in Practice: (if applicable)
Office Contact Name/Office Manager:
Street Address: **
Suite/Floor/Building/Box:
City: **
State/Province: **
Zip/Postal Code: **
Country:
Address is: Office Home
Primary Phone: **
Secondary Phone:
Fax:
E-mail: **
Emergency Contact Name:
Emergency Phone:
Purchasing Information:
ARBO Tracker ID: (if applicable)
Allied Certifications
(check all that apply, if applicable):		 ABO
AOA Para
JCAHPO
NCLE
License 1:
License 1 State:
License 2:
License 2 State:
License 3:
License 3 State:
Do you wish to receive the monthly SECO International e-Newsletter? Yes No
SECO 2011 plans to incorporate text messaging updates during the congress. You will receive general information such as course room changes, etc.
Note: Your mobile phone number will NOT be shared with any third parties.
Please check one: ** Yes, I would like to receive
No, I would not like to receive
If your mobile phone is not web-enabled you can still sign-up to receive text announcements and special offers.
*Standard text messaging and data rates may apply from your carrier.
Mobile Number :
Please tell us what kind of mobile device you use:
**Privacy Statement: By checking this box, I agree to the terms and conditions of the privacy policy, as outlined by SECO International, LLC. I also agree to allow SECO International to use my contact information to contact me about information related directly to the congress.