OPA New Member Application
Give yourself the gift of an OPA membership!
2013 Dues Year
Active Member - $250
Joint Member with Current Active Member Spouse - $130
First Year Pharmacist - (2012 Graduate or Resident PGY1) - $85
Second Year Pharmacist (2011 Graduate or Resident PGY2) - $165
Retired Member
(Must be 65 & retired from full-time practice.)
- $100
Associate Members:
Primary Associate - $190
Additional Associate - $100
Additional Associates must provide the name of the Primary Associate member from your company below.
(non-pharmacist only - enter N/A in OH License #, College Attended, and Graduation Year fields to proceed.) -
New Member Name
(First/Middle/Last)
OH Pharmacist License #
Preferred Mailing Address:
Home
Work
Home Address
City/State/Zip
Company
Work Address
City/State/Zip
Email
Home Phone
Work Phone
Fax
College Attended
Graduation Year
R.Ph
PharmD
Other
Employment Type
choose one
Educator
Manager
Staff
Administrator
Owner
Other
Practice Setting
(*First Year Ohio pharmacists receive a complimentary OPA membership through January of the year following licensure.)
Membership Rate:
choose one
Active Member $250
Joint Memb w Current Active Memb Spouse $130
1st yr RPh or PGY1 2012 Grad $85
2nd Yr RPh or PGY2 2011 Grad $165
Retired Member Must be 65 retired from full time practice $100
Primary Associate Member non pharmacist only $190
Additional Assoc. Member with Primary Assoc. non RPh only $100
Primary Associate's Name:
(For Additional Associate's use only.)
How did you hear about OPA?
If you’d like to make a voluntary contribution to the Ohio Pharmacy PAC, OPA’s political action committee, please fill in the amount in the space provided below. (Personal contributions only.)
PAC Contribution
I affirm that my OPA Pharmacy PAC contribution has been made with non-corporate funds.
If you’d like to consider making a charitable contribution to the Ohio Pharmacists Foundation, please fill in the amount in the space provided below.
OPF Contribution
- denotes required fields
