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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 - (2013 Graduate or Resident PGY1) - $85

Second Year Pharmacist (2012 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
Practice Setting
(*First Year Ohio pharmacists receive a complimentary OPA membership through January of the year following licensure.)

Membership Rate:

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