Licensed Physician Assistant Membership Application

PROFESSIONAL INFORMATION
LICENSING / EDUCATIONAL INFORMATION
PERSONAL INFORMATION (NEVER SHARED)

(For Alliance Use)

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Payment

If there is no day included in your expiration date, select the last day of the expiration month.

OMA Dues for Physician Assistant Members are $75.00. Please make check payable to Oregon Medical Association and mail to 11740 SW 68th Parkway, Suite 100, Portland, OR 97223

AGREEMENT

I hereby apply for membership in the Oregon Medical Association and agree to abide by its bylaws and policies and the Principles of Medical Ethics of the Oregon Medical Association. I authorize the OMA and its affiliates to communicate member benefit information by e-mail and facsimile.

OTHER

Contact the OMA if you have any questions regarding your application at (503) 619-8000 or send an e-mail to oma@theOMA.org.

v2 2016