OPTIP Membership Application

* Required  
*Clinic Name:
Street Address:
City, State, Zip:
*Phone:
Fax:
*E-Mail:
Clinic Owner(s) Name:
Business/Office Manager's Name:
Additional (Satellite) Clinic Locations:
Clinic Name
Street Address
City, State, Zip
Phone:
Fax:
E-Mail:

Areas of interest or issues you would like to see OPTIP address this year:

Message:

FEES:
Physical Therapy Clinic One Owner/Manager $ 350.00
Each Additional Physical Therapist or Owner $ 100.00
Each Satellite Clinic per Location $ 50.00
Self-Employed Physical Therapist (not a clinic owner/manager) $ 125.00

Make your check payable to OPTIP & mail to:
Diana Godwin
1500 NE Irving, Suite 370
Portland, OR 97232

Phone: contact Diana or her assistant at (503) 224-0019 Fax: (503) 229-0614

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