Please Wait...
Thanks for deciding to support our project.
Membership No (If known):
Title
First Name
*
Last Name
*
Phone
Mobile
Date of Birth
Email
*
Organisation
Pay on behalf of this Organisation
Suburb
City
Country
Country
Select your country
New Zealand
Australia
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
S. Georgia and S. Sandwich Islands
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and The Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Soviet Union
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom Of Great Britain & Northern Ireland
United States of America
Uruguay
US Minor Outlying Islands
US Virgin Islands
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Search for your address
*
Search for your address
*
Address
*
Address 2
Suburb
City
Post Code
*
State/Region
Region
Financial Details
I would like to gift a membership to someone
Who will receive this gift?
First Name
*
Last Name
*
Email
*
Mobile
Country
Search for your address
Search for your address
Address
Address 2
Suburb
City
Post Code
Region
Please let us know if you work at other Practices so we can include this on our website and send you additional certificates
Second Practice Name
Second Practice Address
Additional Practice Names
Additional Practice Addresses
Membership Type (Includes GST)
Ophthalmologist Individual $500.00
Optometrist Individual $200.00
I am renewing my membership
Apply
Membership:
NZD
I would also like to include a donation:
NZD
Total:
NZD
Payment Method
Pay using
Credit Card
Name on card
*
Credit or Debit Card Number
*
Security code
*
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
Bank Account
*
Denotes mandatory field
Please tick the box to accept the Terms and Conditions
View Terms and Conditions
Please tick the box to accept the Terms and Conditions
View Terms and Conditions
Submit
Powered by vega.works
Just a few last questions
Yes
No
Yes
No
Yes
No
First name
Last name
Email
Thank you we will be in touch shortly
×
Close
...