MISSOURI OPTOMETRIC ASSOCIATION

MOA -PACContributionPolitical ActionSupporting OptometryName: _______________________Phone:______________________________Street: ___________________________________________________________City: __________________________State_____________________Zip______[ ] I wish to support Optometry in Missouri with a check in the amount of:____$1000 ____$750 ____$500 ____$250 ____$100 Other $_______[ ] I wish to support Optometry in Missouri with a monthly charge on my credit card in the amount of:____$100 _____$75 ____ $50 _____$25 Other $_______[ ] I wish to support Optometry in Missouri with one time charge on my credit card in the amount of:____$1000 _____$750 ____ $500 _____$250 ___$100 Other $_______Visa or MasterCard ____________________________________ Expiration_____________________________________________________________________________(Signature)Return to:MOA-PAC Box located at the MOA Annual Conference Registration TableorMOA • 100 E. High St., Ste. 301 • Jefferson City, Missouri 65101 • Fax: 573-635-7989