REGISTRATION

Membership Application

Please fill out the form below to subit your application for membership to OAPHD online.

If you wish to pay by cheque, please include the information in the membership form outlined below and forward to:

OAPHD

c/o Charlene Plexman

Public Health Sudbury & Districts

1300 Paris Street

Sudbury, Ontario  P3E A3A

 

Please Note:  When filling out the membership form be sure to fill out the first section below for the individual applying for membership - NOT - the individual entering the information or involved with payment.  Payment in full may not denote acceptance of membership.  If your application is not accepted, your fee will be returned in full.

If you do NOT have a PayPal account you can still pay using a credit card by clicking on the 'Pay with Bank Account or Credit Card' as highlighted below:

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You can securely fill in the required credit card information on the next page that lets you to pay without opening a PayPal account.

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Prefix:*
Name:*
Health Agency:
Address:
Work Phone:*
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Cell Phone:
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E-mail:*
Select type of membership:*
1. Who is paying for your OAPHD membership?
Other (please specify):
2. Is this a renewal of your membership from last year?*
If no please attach job description:
3. Please note your position held at Agency:*
4. Professional designation:*
5. Is your primary employment in Dental or Oral Health? *
Comments:
6. Other dental or or public health associations you belong to:
Please click below: