Please indicate program(s) for which you are applying:

Residency in Pediatric and Visual Rehabilitation Optometr, The Eye Center at SCO
Primary Eye Care, The Eye Center at SCO
Primary Care, SCO/CBU Combined Residency Program
Vision Therapy and Rehabilitation, The Eye Center at SCO
Cornea & Contact Lens Refractive Surgery, The Eye Center at SCO
Low Vision and Ocular Disease, Hampton (VA) VAMC
Low Vision/Primary Care, Ralph H. Johnson (SC) VAMC
Family Practice Optometry, West Tennessee Eye
Ocular Disease (Southern Eye Associates of Memphis)
Ocular Disease, Hyde Eye Car, (TN)
Primary Eye Care, Memphis VAMC
Primary Eye Care, Dorn (SC) VAMC
Primary Eye Care, Salem (VA) VAMC
Primary Eye Care, Salisbury (NC) VAMC
Primary Eye Care/Ocular Disease Mountain Home (TN) VAMC
Primary Eye Care, Bond-Wroten Eye Clinic, Denham Springs (LA)
Primary Eye Care, Ochsner Medical Center, New Orleans (LA)
Vision Therapy Group, Sensory Learning Center (MI)
Vision Therapy/Rehabilitative Optometry, Appelbaum Eye Care Associates (MD)
Vision Therapy, EyeCare Professionals, P.C. (NJ)
Vision Therapy and Rehabilitation, The Vision and Learning Center at Family Eyecare Associates, P.C. (NJ)
Vision Therapy and Rehabilitation, Wow Vision Therapy LLC (MI)
Vision Therapy/Pediatric Optometry, Vision Care Specialists (MA)
Pediatric Optometry/Vision Therapy & Rehabilitation, Child & Family Optometry (KS)
Refractive and Ocular Surgery/Ocular Disease, Woolfson Eye Institute (GA)

Note: All applicants must also complete the Optometric Residency Matching Service Application.

1. Full Name: (first, middle, last):

2. Present Mailing Address:

Telephone Number:

Email Address:

3. Permanent Mailing Address:
Same as above.

Telephone Number:

4. Social Security Number:

5. Are you a citizen or permanent resident of the United States?
Yes, my state of legal domicile is:
No, my status or type of visa is:

6. List all colleges (undergraduate and graduate including optometry) attended:

7. List any extern program or clinical experience which is relevant to your application:

8. How did you first learn of the residency program to which you are applying?

9. State briefly how you feel the residency will help your optometric career.

10. Do you have a license to practice optometry? Yes No
If yes, which state(s)?

11. Please forward the following official transcripts to the Director of Residency Programs:

A. Optometric
B. NBEO (ORMS and the NBEO have entered into an agreement for ORMS to supply NBEO Parts I and II scores during the last weeks of February to programs where you apply and Part III scores (when they are available in June) for all matched candidates. This service is provided at no cost to you by ORMS; your scores are obtained using your OE Tracker number.)

12. Three letters of recommendation as listed in the program description must be forwarded to the Director of Residency Programs.

The College affirms that no person shall, on the basis of race, color, creed, religion, sex, age, disability, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity at Southern College of Optometry.