| asterisk (*) indicates required field |
| General Information |
| * Applicant First Name |
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| * Applicant Last Name |
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| * Applicant Date of Birth (MM/DD/YYYY) |
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| * Applicant Gender |
Male
Female |
| OCP # |
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| Year of Graduation (if applicable) |
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| OPA Membership # (if currently a member) |
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| OPA Membership Type (if currently a member) |
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*Primary Address (required) |
Alternate Address (optional) |
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| primary address will be used for contact purposes |
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| A: Membership Information - Choose the desired membership category |
Rates include all applicable taxes. Please note - Ontario College of Pharmacists (OCP) mandates that Individual Professional Liability insurance is required even if pharmacy insurance provides professional liability insurance for pharmacists.
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Full Membership |
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Full Membership Includes voting privileges and full benefits - One must be a licensed practicing pharmacist in Ontario in good standing with the OCP
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Full with Professional Liability ($2,000,000/claim-$4,000,000/annual aggregate) $645.30 |
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Full Membership without insurance $514.50 |
Spousal Membership |
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Spousal Membership Includes voting privileges and full benefits. When 2 Full Member pharmacists reside in the same household, one may apply to this category, and only one mailing will be sent
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Spousal with Professional Liability ($2,000,000/claim-$4,000,000/annual aggregate) $604.88 |
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Spousal Membership without insurance $472.50 |
Supporting Membership |
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Supporting with Professional Liability ($2,000,000/claim-$4,000,000/annual aggregate) $424.80 |
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Supporting Membership without insurance $294.00 |
Supporting Membership Includes NO voting privileges. Indicate which of the following is applicable:
65 years of age or older as December 31, 2007
CSHP Ontario Branch member also working in a hospital pharmacy
Disabled - Totally disabled as defined by OPA Insurance Program
Out of Province - Resides outside of Ontario with a Canadian license
Non-Registered - Pharmacists no longer licensed to practice pharmacy in any jurisdiction (subject to approval by membership department, those whose licenses are revoked do not qualify)
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Student Membership |
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Student with Professional Liability ($2,000,000/claim-$4,000,000/annual aggregate) $231.24 |
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Student Membership without insurance $58.44 |
Student Membership Proof of enrollment at your educational institution is required. Indicate which of the following is applicable:
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Anticipated year of Graduation: |
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Introductory Special |
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Introductory Special NO voting privileges, limited benefits. Available only to individuals who have not been members since 2005 or earlier. One time offer, see the membership brochure for complete details.
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With Professional Liability ($2,000,000/claim-$4,000,000/annual aggregate) $318.75 |
Pharmacy Technician |
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Pharmacy Technician The membership period for this category is April 1 – March 31. NO voting privileges, All standard benefits apply (other than Insurance Program).
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Pharmacy Technician $91.13
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| B: Professional Liability Insurance |
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To apply or upgrade your Professional Liability Insurance, complete the following questions:
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*Has any claim been made or suit brought against you on account of any actual or alleged malpractice, error or mistake?
Yes (An addendum may be requested)
No
*Do you have any knowledge of any act which might give rise to a claim under this policy or do you anticipate any claims being brought against you?
Yes (An addendum may be requested)
No
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Professional Liability Insurance Upgrades |
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Available to members who purchase membership with $2,000,000/$4,000,000 insurance option
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Professional Liability |
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($5,000,000/claim-$5,000,000/annual aggregate) $118.80 |
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Legal Expenses |
$25,000/claim, $75,000/annual aggregate $37.80
$50,000/claim, $150,000/annual aggregate $48.60
$100,000/claim, $300,000/annual aggregate $70.20
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clear selection |
Your Total:
(Includes applicable taxes. Payent information will be requested on the next page) |
| Disclosure Statement |
| The information provided by me on this application is, to the best of my knowledge, accurate and complete. Any and all member benefits, provided in good faith by OPA, and entered into by me, are at my own risk. The OPA is not liable for any actions resulting from my personal or business decisions. |
Upon successful on-line payment, you will receive a receipt via e-mail. If you don't receive your e-mail confirmation, please contact Wendy Furtenbacher at 416 441 0788 or
877 341 0788 x4224. |
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