LAEPS Membership Renewal

Personal Information

First Name*

Last Name*

Primary Office / Practice / Institution Name

Address

City

State

Zip

Email*

Phone*

Practice Administrator

Practice Administrator Email

Membership Type and Dues

Membership Dues Amount*

Active Member Dues $600

2nd Year New Physician $300

1st Year New Physician No Charge

Ophthalmology Residents No Charge

Ophthalmology Fellows No Charge

Retired No Charge

Donation Amount: (WITHOUT dollar sign)

Comment

Payment Information

Total Amount

$

Payment method *

Credit or Debit Card
Pay by check.
Please mail to:
LAEPS, P.O. Box 80053, Baton Rouge, LA 70898-0053

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Type*

Card Holder Name*

Contact Info

Louisiana Academy of Eye Physicians and Surgeons

P.O. Box 80053
Baton Rouge, LA 70898-0053

Phone: 225-933-5435
Fax: 225-208-1932

director@laeps.org

Membership Dues

To join now as a new member, click here »

To renew your dues for 2019, click here »

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