Organizational Membership Application

Thank you for your interest in becoming an OPHA member for 2021/22. Membership will end March 31, 2022. Please complete all applicable sections of the following form.

At the end of the membership cycle, your membership will automatically renew for another one-year term at a rate of $2000, unless you provide notice to us of your intent to terminate your membership at least 30 days before your membership expires. Please contact membership@opha.on.ca for more information or to cancel your renewal.

Become a member

Membership *

Organizational - $ 500.00

Please renew my membership automatically.

Total Amount

Email Address *

Organizational Membership Registration Form

Organization Name *

Street Address *

City *

Country *

Province *

Postal Code *

Phone (Main) *

Email (Main) *

Please enter a Username to create an account. If you already have an account please login before completing this form.

Username *

Check Availability
Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores.

Organizational Member Point of Contact

Title

First Name *

Last Name *

Job Title

OPHA Member Networking Directory *

Yes No

Through OPHA’s new online networking directory, you will be able to find and connect with other members who may share similar backgrounds and areas of interests, unless you opt out.

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *

Username
Password

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